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Monthly Archives: October 2010

Patient Communication

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Unfortunately, this post is not original to me. My mother, who is also a nurse, emailed it to me. Not sure of its origin.

A sweet grandmother telephoned St. Mary’s Hospital. She timidly asked, “Is it possible to speak to someone who can tell me how a patient is doing?”

The operator said, “I’ll be glad to help, dear. What’s the name and room number?”

The grandmother in her weak, tremulous voice said, “Samantha Chase, Room 203.”

The operator replied, “Let me place you on hold while I check with her nurse.”

After a few minutes the operator returned to the phone and said, “Good news.  Her nurse has told me that Ms. Chase is doing very well. Her blood pressure is fine. Her blood work just came back as normal and her physician, Dr. Kohler, has scheduled her to be discharged Tuesday.”

The grandmother said, “Thank you. That’s wonderful! I was so worried! God bless you for the good news.”

The operator replied, “You’re more than welcome. Is Ms. Chase your sister?”

The Grandmother said, “No, I’m Samantha Chase in 203. No one tells me $^!# around here.”


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Dying to Be Sick – Part 2

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Earlier this week I posted about a patient who was malingering. This post is similar, but more disturbing.  As with all the stories I post here, I changed enough of the details to keep identities private.

I took care of an 18 year old boy named Tom.  His mother, Martha, brought him in for his ongoing chronic condition.  She claimed that he had been sick since birth.  He had several implanted tubes to manage his condition including two types of feeding tubes and a central line.  He had not taken oral nutrition in years. Instead he received all of his nutrition through his central intravenous line, a dangerous, expensive treatment.  He also seemed to be developmentally delayed.  He had volumes of medical records that were scanned into our e-chart system and Martha also kept a binder of medical records at the bedside.

As our physicians got to know Tom, Martha, and the tome of medical records, they began to find inconsistencies in the chart.  Soon, all the tests they ran on Tom came back saying that Tom was fine.  The physician continued to dig. The chart included a letter from a physician stating that Tom was on a transplant list in a neighboring state.  The shrewd physician dug a little deeper.  He eventually discovered that the letter was a complete forgery.  Our physician contacted the out of state physician who had never heard of Tom or Martha.

While I’d seen patients play up their symptoms, what was going on here was much more disturbing.  This condition is called Munchausen Syndrome by Proxy.  It is a serious psychological disorder and form of child abuse.  Caregivers fabricate symptoms and episodes for secondary gain, perhaps attention or other perceived benefit. Tom had gone through endless tests and procedures, any one of which could have harmed or killed him.  The fact that he was young and developmentally delayed made him very vulnerable.  The physician referred the patient to psychiatric services and I really hope they both got the help they needed.  It unknown how many children are harmed by Munchausen Syndrome by Proxy.  It is thought to be uncommon and hopefully most caregivers don’t get as far as Martha did.

Dying to Be Sick

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For the most part, people don’t want to be sick and don’t want to be in the hospital. However, I’ve learned that there is a small minority of patients who are desperate to be sick. It’s amazing what lengths they will go to.

One woman came in complaining of a bloody nose.  It was enough blood that she was admitted. The patient was on blood thinners which can often cause bloody noses.  She stated that she was on blood thinners because of a problem with clotting. By her count, she’d thrown 5 clots to her lungs (called a PE or pulmonary embolism) in the last few years.  Because you can die from a PE, she was put on blood thinners to prevent further clots. She also had a filter installed in one of her major vessels to prevent further clots from getting to her lung– a somewhat invasive procedure.

The physician caring for the patient started looking at old CTs and other imaging.  Turns out the patient had never once had a clot show up on any imaging. Her blood work also showed no signs of confirmed clot. Digging a bit deeper the physician noted that the patient used to work in the medical field and would know the symptoms of a lung clot: sudden onset of shortness of breath, chest pain, sweating, cough, anxiety, and even “impending sense of doom.” This woman had talked her way into a filter in her blood stream, blood thinners, and multiple hospital admissions with no objective sign of anything wrong with her at all.  After paying closer attention we discovered she would only get nose bleeds after she had been left alone in the room long enough to cause one herself.  They re-tested her blood and discovered that she was still secretly taking blood thinners, perhaps to keep the nose bleeds coming.

She was one of my first malingering patients and I couldn’t figure out why she would be doing such a thing.  Turns out she was a mother of a small child and her husband was serving in the military in a war zone.  She asked the doctor to write a letter for her saying that she was too sick to care for her child and needed her spouse to come home.  I felt terribly for her.  She felt that she needed her husband back so badly that she would risk her own life with unnecessary medications and procedures.   Unfortunately for her, the doctor had picked up on her true motive and couldn’t write the letter for her.  She left immediately. My guess is that she went to another hospital to try again.  Because of the way privacy laws are, her physician would not and could not try to notify other physicians of the ploy.

The All-Important Brain

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Update: I made a dedicated page for report sheets.  It’s here http://wp.me/PDtM3-47.  Also, you can find a Spanish to English translation sheet for nurses for free here.

Nurses often use a “report sheet” to take notes on our patients and remind of us of tasks that have to be completed before our shift ends.  These single sheets of paper are so important that we often call it, “our brain.”  Losing your report sheet halfway through the shift or accidentally dropping it in the iron clad “Shred-It” bin (done it) or toilet (done that too) can be devastating for your shift.

There are a lot of different templates floating out there that nurses use to keep track of patients. I’ve attached a few favorite, free report sheets.  Let me know your thoughts and send me your favorite “brain!”

Some brains to peruse:

1) Becky Report Sheet

2) Lindsay Report Sheet

3) Denise Night Report Sheet

4) Denise Day Report Sheet

5) Sarah: Four Patients, 7A Shift

6) Stephanie: 6 Patients, 7A shift

Explanation of abbreviations

Update:

I came upon a website that has a lot of report sheets on it. You can check it out here. This nursing website also has several. Just search for “report sheets.”

Update: I made a dedicated page for report sheets.  It’s here: http://wp.me/PDtM3-47.  There are more sheets there. One sheet I designed for students. The “Lindsay” sheet is the one I use.