Hydrocephalus

[KelRN215, BSN, RN]

I am so mad about something that happened yesterday. I began my career in pediatric neurology/neurosurgery and have seen my fair share of hydrocephalus emergencies over the years. Currently I have a patient who I see who is s/p myelomeningocele at birth, untreated hydrocephalus, Chiari II malformation. The social situation is extremely complex, CPS was involved with the family before the baby was even born, and the mother is currently inpatient herself due to a medical issue that arose soon after the baby was born. Yesterday I go to see the baby- he's normally calm, alert and interactive. The neighbor who was watching him said he'd been screaming all day and wouldn't settle. He cried the entire time I was there and had all the signs of worsening hydrocephalus- fontanelle is tense, head circumference is up, no up-gaze, vomiting with every bottle. After speaking with the on-call Neurosurgery Resident, it was decided that he needed to be seen. His VS were ok so my initial idea was to just have Dad come home and drive him in. Come to find out, Dad- despite having a car- is not a licensed driver and there wasn't anyone to bring him in. The neighbor he was with had let him scream for 7 hours and vomit with every feed without so much as calling anyone (despite having been told the signs of hydrocephalus multiple times) and the baby had also sustained a skull fracture/bleed last week. There was NO WAY I was going to leave and just hope that someone with a car would eventually show up to drive them to the hospital, so I called 911 and sent him in via EMS. His primary Neurosurgeon initially felt- based on the clinical picture as I reported it- that the time to treat his hydrocephalus had probably come. THEN, the On-Call Attending (who is apparently a little full of himself according to my former colleagues) goes and says "After talking to Dad, what we're mainly dealing with is overreaction on the part of the visiting nurse." I was so rip-roaring mad when I heard that.

First of all, Dad had left him with the neighbor at 8am so had no idea what he looked like when I was there at 3pm. This baby had all the classic signs of hydrocephalus. They keep wanting to say that his increased head circumference is just normal growth but he's gone from the 12th to the 18th to the 23rd to now the 50th percentile and his weight is only in the 30th percentile. Do I have X-ray vision? I can't see what's going on inside the baby's head. Am I supposed to just do nothing with a baby who's showing all the signs of hydrocephalus who's got a caregiver who's let him scream and vomit for 7 hours under the assumption that the Neurosurgeon will probably not want to treat? Who will get blamed in that instance when the baby is dead in the crib the next morning? They did end up admitting him but it aggravates me beyond belief when surgeons are so dismissive. I forgot how aggravating they are to deal with, I mostly deal with PCPs and Oncologists now and they are very responsive to me.

Happy freaking nurses' week.

[NotReady4PrimeTime, RN]

My blood is boiling over this. None of our neurosurgery staff would EVER speak to or about a nurse in that way. If they did and it got back to the medical director - the sweetest, mildest, gentlest person I know - he'd publicly rip them a new one. The kid was demonstrating classic increased intracranial pressure. And had you not intervened, you're right... the risk of finding him cold and blue from herniation was just too high. Better safe than sorry. My guess is CPS will be looking into things further. And so they should. I'm sorry this happened to you, but you can rest assured I would have done the same thing. Sometime I'll tell you about the 11 year old whose life I saved when I was a very new, very frightened home care nurse at the risk of losing my much needed job.

[KelRN215, BSN, RN]

These Neurosurgeons have a long history of ignoring hydrocephalus until it's an emergency. I saw it for years when I worked there. I watched them pull EVD after EVD on a baby with aqueductal stenosis to see what would happen only to have her hemorrhage and be rushed back to the OR within hours MULTIPLE times. I had them tell me that it was "fine" that her HR was 80. She was 2 months old. Less than an hour later she was in status epilepticus with widening pulse pressure and we were pushing her crib directly into the OR. I've had them tell me that "we're just going to go by the heart rate" with kids bordering on shunt malfunctions. Apparently they don't teach in Neurosurgery that vital sign changes are a LATE sign of increased ICP. Anyway, as far as I know the baby is still inpatient... they decided it was necessary to do a full work-up including an MRI with sedation...

[~PedsRN~, BSN, RN]

Of all the specialties that I work with, neurosurgery is by far the one that I like THE LEAST. I have never met one of the surgeons that wasn't suffering from the God Complex. Try not to take it personally. Know that you acted as that child's #1 advocate! I'd rather have a root canal than work solely in peds neuro. :***:

[toomuchbaloney]

Personally, I would complain loudly and where ever necessary to make the obnoxious doc understand that there is a TEAM of health professionals who provide care for patients and that HIS REMARKS are certain to decrease patient/family satisfaction scores since he went out of his way to throw a team member under the bus.

[NotReady4PrimeTime, RN]

I guess I'm exceedingly lucky to work with a group of extremely competent and very respectful neurosurgeons. Not one of them is a prima dona. They treat us as partners in care and even when things go sideways, there's no standing in the middle of the unit shouting. One of them told me he wanted me to be involved in all of his patients' care. I was flattered to no end.

[~PedsRN~, BSN, RN]

I guess I'm exceedingly lucky to work with a group of extremely competent and very respectful neurosurgeons. Not one of them is a prima dona. They treat us as partners in care and even when things go sideways, there's no standing in the middle of the unit shouting. One of them told me he wanted me to be involved in all of his patients' care. I was flattered to no end.

When you go to work, do you travel through a wardrobe into a magical place called Narnia? LOL!!!

Can your docs call mine and teach them their ways?

[NotReady4PrimeTime, RN]

No, it's more like falling through the rabbit hole... into Not-So-Wonderland. One of our cardiac surgeons more than makes up for the neurosurgeons. Our GI transplant surgeons are all pretty high on their own selves, even though they're really not that great. And we used to have an ENT surgeon who was even worse. We have a couple of anesthesiologists who are vile, evil snarly people. It's not Narnia, for sure.

[~PedsRN~, BSN, RN]

Hahahah! I guess every hospital has *those* doctors, eh? :) Too bad, I was ready to find out where you were and get a job there. HA!