what to do if you disagree with PA's treatment

Published

Specializes in 12 years as a school nurse.

Hi all, I would like your opinion on what you would do if you thought (knew) that the treatment recommended by a PA was not appropriate? I have a kinder student with tinea captitis (ringworm of scalp) and the PA's note to the school states that Ringworm is not contagious due to treatment with topical antifungal cream. It is my understanding that when ringworm gets into the hair follicles, the topical creams are ineffective treatment because they do not penetrate deep enough. In the case of scalp ringworm a prescription for an oral antifungal is required. This is what I told the parent (twice, a week apart), and when they finally took the kid into be seen, the PA did nothing! Said keep treating with the otc athletes foot cream. School policy is exclude until appropriate treatment is started and keep ringworm covered at school. Hard to do that- have student wear a hat?? Also same kid had irritated left eye, red sclera, cloudy exudate in inner canthus and crusted matter in lashes and skin surrounding eye. When I sent home to be evaluated for both possible pinkeye and ringworm without appropriate treatment, mom is not happy. Student returns next day with note from PA that says "ringworm not contagious- treated with topical agent, left eye not conjunctivitis, may atttend school." What would you do?????? Help.

Up Vote Up Vote ×
Specializes in IMC, school nursing.

I counsel my parents to take student to an MD. I had a student continually treated with antibiotics for a cough at the largest pediatric clinic in our area by PAs and NPs when seen for sick visits, he was treated for GERD after being seen by a physician. Mid levels don't know what they don't know, and that is the breakdown in our health care delivery.

5
Up Vote Up Vote ×
Specializes in 12 years as a school nurse.

I really want to call the clinic charge nurse or clinic manager and ask her if SHE considers topical treatment appropriate for scalp Ringworm. And not say student's name as to not violate confidentiality. Mid level providers are the only ones who do walk-in clinic/urgent care around here. It takes 1-2 moths to see an MD. sad.

1
Up Vote Up Vote ×
Specializes in Pediatrics Retired.

Sounds like one of those..."what can I do to get this parent out of my office?" visits. Even though I agree with you, I'd let it ride for now and see how things progress; especially the eye - it'll either get better or worse...time will tell and give you a little more leverage to insist on a follow up if things don't resolve.

8
Up Vote Up Vote ×
Specializes in pediatrics, school nursing.

And if the parent refuses/refutes, involve admin in imploring. Or, ask the family to sign a release for you to discuss with the PA/office.

2
Up Vote Up Vote ×
Specializes in IMC, school nursing.

I understand your frustration, but it isn't our place to diagnose and treat. It took me a while when I started, but you have to respect the extra education that you don't have.

5
Up Vote Up Vote ×
Specializes in Pediatrics Retired.
1 minute ago, MrNurse(x2) said:

I understand your frustration, but it isn't our place to diagnose and treat. It took me a while when I started, but you have to respect the extra education that you don't have.

Agree...the PA card trumps the RN card and such is the rules of the game.

6
Up Vote Up Vote ×
Specializes in 12 years as a school nurse.

I know it's not in my scope to diagnose or treat. The PA did diagnose the ringworm- not me. It is in my scope to follow rules/regs of infection control and school health is my priority. Our policy is to exclude for ringworm until treated appropriately and it must be covered at school until cleared. I'm so tempted to call to clarify or question the treatment as appropriate though. I'm worried that next week I'll have a whole classroom full of kids with pinkeye and ringworm. . . I'm waiting to hear back from my state school nurse consultant for advice. This is a difficult family to work with as is- poor hygiene, poor resources, etc. I really don't think it will get better with this treatment. Thanks all for your comments and advice, I really do appreciate it!

1
Up Vote Up Vote ×
Specializes in IMC, school nursing.
10 minutes ago, nursekoll said:

I'm so tempted to call to clarify or question the treatment as appropriate though.

This is appropriate. You may ask if it is effective to treat follicular infection. Take the angle that you want the child included in class, but you also want to protect the classmates from possible exclusion related to infection. We have to remember that questioning a practitioner is necessary but may be detrimental if the practitioner decides to prove you wrong every time the student is sent with a concern from the school nurse. I try to say to the parent the symptoms I am concerned about and not give any condition, that way those practitioners with soft egos don't misdiagnose to prove me wrong.

9
Up Vote Up Vote ×
Specializes in ICU/community health/school nursing.

What is your district policy on ringworm? I believe ours is "covered may return to class" - and I don't know how you'd cover a scalp in a way that did not subject the student to ridicule. Providers often write OK to return notes when that does not meet with the school policy. Policy will trump provider if you push it. Good luck!!!

4
Up Vote Up Vote ×
Specializes in Community and Public Health, Addictions Nursing.

Tricky situation here...and I agree that making a provider feel like you're disagreeing with them/challenging them/trying to hurt their ego (even when you're just trying to help the kid!) will only come back to bite you.

Usually, if we allow kids back to school once treatment has been initiated, it's with the expectation that they're starting to get better. Does this kiddo's scalp look any better, or is it the same? Maybe some regular scalp checks with a plan to notify the provider after X days of no improvement would be helpful. We had a form that we would write down brief assessment info on and ask the family to take to a doctor's appointment, then return to us with the doctor's recommendations.

As far as spreading ringworm to other kids goes, there's evidence that topical treatment can help to reduce transmission, so I guess I would take small comfort in the thought that something's being done. Though I agree, the sooner this ringworm can be cleared the better- especially for the student who has it!

2
Up Vote Up Vote ×
Specializes in 12 years as a school nurse.
21 minutes ago, UrbanHealthRN said:

As far as spreading ringworm to other kids goes, there's evidence that topical treatment can help to reduce transmission, so I guess I would take small comfort in the thought that something's being done. Though I agree, the sooner this ringworm can be cleared the better- especially for the student who has it!

This is the only solace I can offer the teacher at this point! Thanks!

3
Up Vote Up Vote ×
+ Join the Discussion