Monday, July 30, 2012

Amanda Trujillo - Nurse Interupted

I am just now hearing about the case of Arizona Nurse Amanda Trujillo and readers of EverythingHealth may also have missed this conflict between a Hospital, the Arizona Board of Nursing and a nurse advocating for her patient.  Nurses across the Country are blogging about it but I've seen very little from Physicians.  I think it is an important story and here is what happened:

Ms. Trujillo, a registered nurse of six years specializing in cardiology, geriatrics and end of life/palliative care,  was caring for a patient who was being evaluated for a liver transplant in the hospital.   According to Nurse Trujillo, the patient did not understand the complexity of what she would undergo,  nor did she know there were other options.  In the course of her assessment she reviewed the procedure and educated the patient with approved patient education materials.  After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.”  The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries.  Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care.  The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.”  The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.   The patient requested a case management consult with hospice to explore palliative care and the Nurse ordered it and documented the conversation in the chart.  She also used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in the Hospital policy when she handed off care of the patient to the day shift nurse.  (this according to State Board Inquiry documentation)

 The next day the physician was unhappy that the planned surgery was in jeopardy and he refused to let the patient visit with hospice.   He accused Ms. Trujillo of acting outside of her scope of practice and the nurse manager became involved as did Hospital administration and Amanda Trujillo was fired for writing an "order" for case management.

This case went through the Arizona State Board of Nursing and her license has been suspended. As a single mother of three, she is unable to find work as a nurse and subsequently she was ordered to undergo psychiatric consultation by the Arizona State Board of Nursing.  She has appealed revocation of her license and it remains "under investigation status".

I am amazed at this case.  That an RN could be fired and have her license suspended for educating a patient and ordering a case management consult is a travesty.  In my hospitals, if there was a difference of opinion, an official ethics consult would be obtained and objective professionals would help resolve any conflict.  We put the "patient first" and that means whatever helps the patient achieve their life goals is what we support.  It isn't about what the doctor wants and it isn't about limiting nurses in educating patients.  Nurses and physicians should support this philosophy and, in the best of worlds, work together to deliver on it.

Amanda Trujillo has been dealt with unfairly.  Plain and simple.  And I wonder what happened to the patient? 

Addendum:  There are many sides to a story and the Trujillo case is complicated if you take into account the other allegations by the Arizona State Board of Nursing (ABON).  Her license was suspended pending investigation of other presumed professional lapses along with this one.  You can read it here.

Thursday, July 26, 2012

States Medicaid Expansion Saves Lives

Some experts have said that individual States and the decisions they make around health care reform will have more impact on people than the Federal Government and the Accountable Care Act (Obamacare).  Since States will be able to "opt out" of of the reform law's Medicaid expansion, where a person resides may have a huge impact on their health.

A new study published in the New England Journal of Medicine by researchers at the Harvard School of Public Health compared death rates in three states that expanded Medicaid in the past decade - Arizona, Maine and New York, with four neighboring states that did not - New Hampshire, New Mexico, Nevada and Pennsylvania.   They looked at data from adults age 20-64 for five years before and five years after the expansions.  They found that expanding Medicaid eligibility lowered mortality rates by 6.1% compared to States that did not expand.  They also found that death rates declined the most in minorities and residents in lower-income counties.  Additionally there was an increase in individuals who reported their health status as "excellent" or "very good".

The study was conducted long before the Supreme Court hearings on the ACA law.  A similar study looking a Medicaid expansion in Oregon showed that the Medicaid recipients see doctors more often and report better health and better financial stability.

There is no doubt among experts that increasing insurance benefits and access to health care improves overall health.  Isn't that what we, as a Nation, want for our citizens?  Medicaid currently covers needy parents and children, low-income disabled people and the indigent elderly who need nursing home care.  The ACA calls for the expansion of Medicaid to lower-income childless adults.  Begining in 2012, Medicaid expansion in combination with the Affordable Care Act's state exchanges should allow most uninsured Americans to finally get affordable coverage.

Under the ACA, the Federal government will pay 100% of the cost for new expansion for the first 3 years, which declines to 90% by 2020.  Why would a State opt out and leave its own people with poor or no health care?  Texas and Florida are two States that refuse to expand Medicaid.  The biggest impact will be on low-income, uninsured women, about 2.4 million and 1.5 million, respectively.  They say they worry that the Feds will be under financial pressure to pay less over years to come.  I have an answer for that!!  We should elect officials that are committed to America's health and that don't look a health care as the first place to make budget cuts.

The fact that a Governor can look his/her citizens in the eye and say "Nope, we don't want to allow our lower income population to get affordable health care, EVEN THOUGH IT HAS NO ADVERSE EFFECT ON OUR STATE BUDGET" is deplorable.  Are we, as citizens, just asleep?  Do we not care because  this topic is just too complicated to understand? 

Are we proud to be a society that is comfortable spending $100 billion a year on wars in the Middle East but think spending $100 billion a year on health care is outrageous?  Our priorities are backward if we do.

Sunday, July 22, 2012

Answer to Image Challenge

The answer to yesterday's image challenge is.....drumroll.....

#1  Congenital nevus.

The skin in this region of the boy's scalp was lightly pigmented, with dark hairs; the lesion had been more pigmented at birth.  A congenital nevomelanocytic nevus was diagnosed.  Such nevi are often present at birth but can develop later in life.  Biopsy or excision is often done since they can transform into melanoma.

These are often called "birthmarks" and can be found on all parts of the body.  Because this was on the scalp it affected the hair growth within the nevus.  Many of these birth nevi regress and shrink with age.

Thanks for playing.  I hope you learned something.

Thursday, July 19, 2012

Let's Start With a Challenge

Re-entry after vacation can be hard so I'll start blogging by asking you to do the work with this New England Journal of Medicine challenge.  This patient was brought in by his parents for the odd discoloration on the top of his head.  What is the diagnosis?

1.  Congentital nevus
2.  Psoriasis
3.  Tuberous sclerosis
4.  Vitiligo
5.  Warrdenburg syndrome type II

Post your answer in the comments and I will post the answer tomorrow!

Monday, July 2, 2012

Blogging Break

EverythingHealth will be taking our own advice and relaxing and experiencing new ventures for 2 weeks.  Please scan the archives or the links on the right for great blog reading.  Enjoy the summer and check back in mid-July.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...