Here we go again, the C.N.A. has spent their members’ hard earned money that they take in as dues to produce (CNA Flyer1) a high-gloss hit piece on yours truly. My oh my how I must frighten the C.N.A., this handicapped, little old lady from Pasadena.

So when I saw the piece that they’re passing out at Huntington Memorial Hospital I felt compelled to respond – since as so many nurses have come to learn from past experience, many members of the C.N.A. like to play fast and loose with not just the rules, but with the truth as well.

First – IStandWithHuntington (ISWH) are the Huntington Memorial Hospital nurses that feel that they don’t need the C.N.A. to represent them. The IStandWithHuntington blog is an alternative voice to the C.N.A. message/propaganda. Nurses whose opinions differ from those backed by the C.N.A. have the right to speak their mind and get their message out and they have chosen to do so – even though it means fending often scurrilous attacks from the C.N.A. “war machine”. They express their opinions, viewpoints and so forth on their blog.

Second – Did I help the ISWH nurses – darn tooting. I contributed to their cause by securing the IStandWithHuntington domain name and offered it to them for their use. They run and have full control over their blog. This isn’t illegal, the ISWH nurses have the right to freedom of speech, just as the C.N.A. members have and for the record Huntington Memorial Hospital hasn’t spent a dime in securing, purchasing or hosting this blog.

Third – The C.N.A. really does need to go back to school if they think I’m a professional union buster. Professional is defined as – a person engaged in a specified activity as one’s main paid occupation rather than as a pastime. I’m not paid to help nurses who want to get their union-free message out. Nurses call, write and email me when they want advice on how to get their message out, on how they can even the playing field and what not. I listen to them and if I think I can help I do what I can do, there’s a whole network of us who believe that nurses can effectively advocate for themselves, without union representation.

Fourth – They’re great about listing my administrative positions that I’ve held over the years, but conveniently leave out that I’m a RN and that I’ve spent more years at the beside as first a Pediatric nurse and then a PICU/NICU nurse than I have in administration. But then again if they did that they might actually provide folks with the impression that I’m a nurse and not some boogey man “union buster”, because nurse = good and union buster = evil, don’t you know.

Fifth – It’s no secret that I don’t support the RN-to-patient ratio, because I support the far superior patient acuity system. Title 22 and Joint Commission mandates an acuity-based system because nurses aren’t workers on an assembly line and patients aren’t widgets. I believe that nurses give the best care when patients are assessed based on the complexity of their illness, care needs and so forth and then matched to the nurse that has the skills, education and training to best meet those care needs – after all that’s why I became a nurse. And I think that’s why most of you became nurses, as well.

Ask yourselves this why does the C.N.A. feel the need to play so fast and loose with the truth, why do they resort to innuendoes, and cast aspersions? This is the union that says they want to represent you and yet they appear to show utter contempt of your fellow co-workers who chose to exercise their to freedom of speech and simply put their message out as well. The ISWH nurses have spent their hard earned money on their effort and whether you agree or not about joining or not joining a union the ISWH nurses are deserving of some modicum of respect. I think their blog has strived to keep their tone civil and information fact based. So just to be clear I’m not about union busting, as the C.N.A. likes to suggest, but I’m am about making sure that these nurses who want to have their message heard get the opportunity to be heard.

The C.N.A. loves the scorched earth technique in dealing with those who disagree with or oppose their viewpoint; do you? Do you want to be associated with a group that feels entitled to denigrate others in our profession because we don’t chose to follow their rhetoric? As nurses we are charged with advocating for our patients, so how can we be expected to advocate for our patients if we can’t even advocate for ourselves? I’m proud to be a RN. You’re welcome to call, write or email me.

By Genevieve M. Clavreul, RN, Ph.D.

Working Nurse Magazine

I know that for a lot of nurses, talking about politics is about as appealing as going to the dentist. However, legislation and policy decisions can shape the way we practice at every level, sometimes dramatically. That’s why it’s important for nurses to pay close attention to proposed laws or new regulations affecting our profession.

Let’s take a look at some current healthcare-related measures and what they could mean to you.

Opioid Restrictions

If you or any of your patients suffer chronic pain and have a liver condition that contraindicates acetaminophen (the active ingredient in Tylenol), you should be very alarmed by S.2134 and H.R.4241.

These bills, prompted by the recent fear-mongering about prescription opioid abuse, would ban Zohydro ER, the only FDA-approved opioid that doesn’t contain acetaminophen. The legislation would also prohibit the FDA from re-approving Zohydro “unless it is formulated to prevent abuse.”

Aside from its impact on chronic pain sufferers, this attempt by some members of Congress to usurp the function of the FDA would set a frightening precedent. If Congress can summarily ban a drug that’s already passed the FDA’s approval process, what’s to prevent legislators from banning other approved drugs, like contraceptives, in hopes of scoring political points? I shudder at the potential consequences.

Safe Staffing Ratios

There’s brighter news in the area of nurse staffing requirements. As most of us know, California has had mandatory nurse-patient staffing ratios for the past decade and Congress is now considering national requirements.

The federal Registered Nurse Safe Staffing Act (H.R.1821 and S.2353), which would apply to all Medicare-participating hospitals, is quite different from California’s rules, which mandate specific ratios for each type of unit. Instead, the proposed federal law would require each hospital to establish a committee — at least 55 percent of which must be RNs providing direct patient care — that will create staffing plans based on patient acuity, staff experience and other factors.

Longtime readers know that I’m very critical of California’s “one size fits all” approach to staffing ratios. I strongly believe that an acuity-based system makes more sense, allowing managers to match nurses to patients based on the nurse’s skills and training rather than arbitrary legislative dictates. The federal law would also give nurses a greater voice in those decisions.

Unfortunately, these bills wouldn’t change California’s current requirements. If this law passes, Medicare hospitals in our state would still need to organize the required committees and create staffing plans, but those plans would have to comply with existing state laws.

Lab Result Reporting

Till now, patients have always been told, “The doctor will call you when your test results come back.” However, in February, the Center for Medicare and Medicaid Services amended the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to give patients the right to request test results directly from the laboratory. All entities subject to HIPAA must comply with the regulation by October 6.

It will be interesting to see how the new rule will affect the patient-provider relationship. Will patients be better informed or will they be panic-stricken after trying to interpret their test results based on Internet searches? Will patients even be informed of the new rule? (I know my and my daughter’s providers have yet to say anything about it.)

If your facility’s lab is subject to CLIA, have you been educated about the new regulation? How do you feel it’s working so far? Drop me a line and let me know.

MRSA and Worker’s Comp

If you’re unlucky enough to contract a methicillin-resistant Staphylococcus aureus (MRSA) skin infection while working in patient care, a proposed state law (AB 2616) would make it easier for you to file a workers’ compensation claim. The bill, which is supported by the  California Nurses Association and National Nurses United, passed both houses of the Legislature in August and now awaits the governor’s signature.

AB 2616 states that MRSA skin infections contracted while providing direct patient care will now be presumed to be work-related unless there’s specific evidence to the contrary. That means if you file an MRSA-related claim, the burden of proof will no longer be on you, which is good news.

Workplace Violence

Workplace violence is an ongoing concern for nurses and other healthcare workers. There’s been some progress since Napa State Hospital psychiatric technician Donna Gross was strangled to death by a patient in 2010, but nursing organizations and unions have been calling for more.

SB 1299, which went to the governor’s office on August 28, is intended to light a fire under the state Occupational Safety and Health Standards Board and push state hospitals to take action. The bill would require acute care and acute psychiatric hospitals to establish plans to prevent workplace violence in both inpatient and outpatient settings.

The plans must include training and education for workers, procedures for investigating incidents, and policies for documenting and reporting incidents to the Division of Occupational Safety and Health, which would be required to post anonymized reports online starting in 2017.

Quicker Licensure

Too many new RNs have passed the NCLEX, graduated from nursing school and started applying for work — only to wait and wait for the BRN to issue their licenses. A bill in the Assembly, AB 2165, seeks to address that problem by giving professional licensing boards a 45-day deadline to issue licenses to candidates who’ve completed all the requirements.

The 45-day clock wouldn’t start ticking until you have completed all the application requirements, so this law wouldn’t help if you had missing paperwork or problems with your background check. The point is to keep qualified applicants from being held up by bureaucratic backlog.

Using our Power

This list is by no means comprehensive. New measures come up all the time, including ones that aren’t specific to nursing, but may still affect our work.

The good news is that we don’t have to sit back and watch idly. With almost 400,000 active RNs in California alone, we have more political power than many of us realize. However, for us to use that power, we have to be aware of what’s going on and willing to get involved. We can’t afford to let politics be a spectator sport.

 

How to Stay Informed

If you want to find out more about these bills and others like them, check out the following links:

•  The Library of Congress THOMAS database allows you to look up information about federal bills.

•  GovTrack.us  is another option for keeping track of happenings in Washington. It requires registration.

•  The Official California Legislative Information webpage includes information on current state laws and proposed legislation.

•  LegTrack is another search engine for state measures. It requires registration.

•  Ballotpedia is “an interactive almanac of U.S. politics,” including neutral descriptions of federal and state measures.

•  The Board of Registered Nursing (BRN) website often provides useful information on pending legislation. The BRN’s legislative committee examines all measures and decides whether the board should support, oppose or watch each measure.

•  Professional organizations and unions such as the American Nurses Association, California and the California Nurses Association/National Nurses Organizing Committee also monitor relevant legislation, although these organizations’ information may be available only to members.

Some professional organizations also organize “lobby days,” which are a great opportunity for nurses to learn about important current issues and the political process in general.

Working Nurse Magazine – Issue

I long ago stopped using Consumer Reports as my go to source for whether a specific product was a good or bad buy, but I was astonished to read their recent article – “Special Report: The danger of painkillers” – published in their September 2014 issue. Their special report once again tried to stoke the flames of fear over opioid use and abuse. The article cites the staggering statistic of almost 17,000 people a year die from overdoses of opioids. While 17,000 people dying every year is indeed an eye-opening number that pales in comparison to the 35,000 who died in automobile accidents in 2013. Consumer reports goes even further to cite that for every death from opioid overdoses 30 people are admitted to the ER for complications of opioid abuse. So after doing the math that’s approximately 510,000 people admitted to the ER for opioid abuse while the National Safety Council “estimated that nearly 3.8 million people suffered crash injuries that required medical attention”. And if you consider that there are nearly 319 million people living in the United States, though 17,000 people dying of opioid abuse is tragic and sad these deaths represent not even 1% of the total population.

Does this mean these deaths should be ignored or minimize, by no means! However, in my opinion I feel that the folks at Consumer Reports should be ashamed of themselves for failing to put the statistics into perspective; but just like the Los Angeles Times they seem to have chosen the approach of fear mongering over ethical journalism. Consumer Reports even dragged out the Zohydro ER “controversy” demanding that the FDA withdraw their approval of Zohydro ER Consumer Reports mentions in their report that attorney generals from 28 states have written the FDA demanding that the FDA reconsider their decision and withdraw their approval of Zohydro ER, as well as the two bills (HR 4241- https://www.govtrack.us/congress/bills/113/hr4241 and S 2134 – https://www.govtrack.us/congress/bills/113/s2134) in Congress that if passed would ban the sale of Zohydro. GovTrack, a excellent source to keep track of legislation both at the federal and state level gives HR 4241 and S 2134 a 2% and 1% (respectfully) chance of being passed by Congress, but don’t you just love it when Congress decides to practice medicine! I know I do.

The Consumer Report article also fails to mention that what separates Zohydro ER from the rest of the opioid pack is that it contains no acetaminophen (aka Tylenol). Why is this important? Simply put, for people living with chronic pain and chronic liver issues, such as Hepatitis C, liver disease and so forth, opioids can prove problematic since acetaminophen is very hard on ones liver, thus any opioid that can provide relief from chronic pain without added acetaminophen is a safer option for those patients in the long run. And Consumer Reports failure to report this very important difference only convinces this person that the folks at Consumer Reports have strayed far afield from their core mission.

Meanwhile, if you’re interested in hearing the FDA’s rationale from their “own lips” then point your browser here – http://www.biocenturytv.com/player/3476140971001

Courtesy Counts in Nursing

By Genevieve M. Clavreul, RN, Ph.D.

Working Nurse Magazine

Being busy is never an excuse for being rude

Nurses are constantly reminded that we are held to higher standards than people in other professions, both at work and in our personal lives. We are judged by how our patients and coworkers perceive us as well as how they perceive our nursing skills. People expect us to be not only competent, but also compassionate and caring.

Unfortunately, nurses often overlook the role that basic courtesy plays in our profession. When stress levels rise, good manners are often the first things to go out the window. We’ve all been there at one time or another when tired or overwhelmed. The consequences of that rudeness can be much more serious than you think.

WHEN CIVILITY FAILS

When it comes to the workplace, politeness might seem like a very trivial issue, particularly in a profession as demanding as ours. Not so, says Pier M. Forni, Ph.D., a professor at Johns Hopkins University and the author of several books on civility and ethics. “Incivility is very costly,” he told David Zax of Smithsonian.com in 2008. “Incivility is both caused by stress and causes stress, and stress is not only a producer of human misery, but is also very costly in dollars.”

Discourtesy costs businesses and organizations a lot of money in the form of reduced productivity and higher turnover rates. Rude behavior in the workplace can make workers avoid each other when they should be collaborating, “tune out” when doing important tasks or even quit. Considering how many talented nurses become burned out, the latter is no small concern.

For healthcare workers, the stress caused by incivility is also bad news for patient safety. The Joint Commission’s 2012 report “Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation” notes that workplace civility is “[c]losely associated with, and perhaps a necessary precursor to, improving safety culture.”

Then there is the problem of lateral violence. Research has repeatedly demonstrated the terrible impact workplace bullying has on nurses and such bullying is all too common. Some researchers have estimated that as many as 85 percent of nurses suffer lateral violence at one time or another and up to 93 percent of nurses have witnessed it. Discourtesy isn’t the same thing as bullying, of course, but an environment in which coworkers are frequently rude to one another and to patients is one in which lateral violence can thrive. So, civility and manners do count and the lack thereof can and does have an impact on our workplace and in turn on our patients.

CHANGING THE ATMOSPHERE

Common courtesy promotes a more positive work environment and allows for better relationships with the people you know and the ones you meet on a day-to-day basis. Good manners convey respect for those with whom you interact and encourage them to respond in kind. A more congenial workplace also makes it harder for lateral violence to take root.

Negativity feeds on negativity, but it is also possible to shift the atmosphere in a more positive direction. Sometimes, all it takes is a few people making the choice to be polite and pleasant.

I often share with people my experience of changing the negative milieu at a local county hospital — not as a nursing director or a nurse, but as a patient undergoing treatment. While the physicians at this hospital had the expertise to provide the treatment I needed, the downside of going there was the very high volume of patients: almost 100 a day. During my first few visits, it was apparent that while the nurses and auxiliary staff were good at their jobs, many treated the patients more like cattle than people.

WHY WEREN’T THE NURSES MORE HELPFUL?

Patients were given little guidance on how to navigate the complex procedures for making appointments or about how to get labs and X-rays done prior to being seen by the doctor. Worse, the nurses seemed to be doing almost nothing to help. I realized that the reason the nursing staff wasn’t trying to making the patients’ lives easier was that no one had made any effort to make the nurses’ lives easier.

Seeing that, I decided to perform simple acts of courtesy like making eye contact, addressing nurses by name and offering a cheerful “hello” to the nurse in the intake line. When I noticed one of the nurses go out of her way to help a patient, I made a point of complimenting the nurse for her act of kindness, remarking that such acts are a fundamental part of our nursing function. I also brought in treats like homemade cookies for the nursing staff.

This reinforcement had a gradual but observable impact in how the nurses treated me. Over time, I also saw the nursing staff demonstrate a bit more kindness and consideration to other patients and even to one another. These were all small things, but they made the clinic a more pleasant place to be and in which to work.

A SMILE GOES A LONG WAY

It’s easy for nurses to blame our lack of courtesy on having one too many patients, not enough ancillary help, being short-staffed and so forth. However, good manners and civility shouldn’t suffer just because we’re too busy.

I have a friend who’s now a plastic surgeon in France. She has a very outgoing personality and greets everyone who crosses her path with a warm “hello” or “good morning” regardless of where she is. As a result, people almost always respond positively to her. Even the curmudgeonly chief of service would find himself smiling (if for only a moment) whenever she entered the room.

Being polite to others is not a one-sided affair. People have a hard time ignoring someone who offers a kind word or other simple courtesies. Taking the time to make these small gestures will go a long way towards achieving positive outcomes in most if not all of our encounters.

Nurses face many challenges in our daily work, but civility and the practice of good manners shouldn’t be given short thrift in the name of efficiency. Courtesy never goes out of style even if people sometimes forget to practice their manners. Let’s make this one of the many areas in which nurses lead the way.

——

10 Ways Nurses Can Be More Courteous

1. Be respectful. Respect is reciprocal. If you want respect from others, you must be prepared to show respect to them as well.

2. Appearances count. Make a point of coming to work in clean, pressed scrubs (or the uniform of the day) and make sure you wear your identification so it can be seen by coworkers and patients.

3. Politeness wins the day. Always say “please,” “thank you” and “you’re welcome” when interacting with your coworkers, patients and their families. It’s easy to forget in the hustle and bustle of the floor, but is always remembered by the people on the receiving end.

4. Voices carry. Whether interacting with coworkers, patients or patients’ families and friends, remember not to raise your voice, use foul language or slang or talk down to others.

5. Promptness is a virtue. There are times when you’ll be late due to some unforeseen circumstance beyond your control, but chronic tardiness is disrespectful and places an additional burden on your coworkers, which breeds resentment and hostility.

6. Gossip is never harmless. Talking or gossiping about a person who isn’t present is disrespectful and generally ends badly for all involved. It harms the person who’s the subject of the gossip and reflects badly on the one doing the gossiping.

7. Don’t ignore people in your presence. The clinical floor isn’t kindergarten. It’s rude to ignore or refuse to acknowledge people when they approach. A polite “hello,” a wave of the hand or a smile will go a long way.

8. Pay attention when someone else is speaking. Show interest, maintain eye contact and listen to what the other person is saying. It’s easy to get distracted when others are speaking, but making the effort to pay attention and show an interest in their thoughts and ideas helps to build a civil work environment.

9. Keep the common areas neat. When in the nurse’s lounge, staff lunch room or other common areas, be sure to clean and put away your dirty dishes. Don’t be a food thief and make sure you keep the refrigerator, microwave and other appliances neat and clean.

10. Use the correct name. Mangling someone’s name or calling someone by a unwanted nickname doesn’t engender positive feelings. If you’re not sure how someone wants to be addressed, ask them. If you’re not sure how to pronounce a name, ask the person to spell it for you (even if that means spelling it phonetically to help you remember the correct pronunciation!).

This list is by no means exhaustive, but these 10 basic tips will prove helpful in most situations.

Rule of thumb when you submit a letter to the editor you should always follow-up to ensure that your letter has been received. This policy has served me well over the years, that is until I tried to follow-up on two letters to the editor that I sent in response to two article the Boston Globe had run on the acetaminophen-free opioid, Zohydro ER .

I felt compelled to respond because I was getting tired of reading and hearing the same incorrect statements being repeated time and time again by various media outlets. Primarily the mischaracterization that Zohydro, which is a hydrocodone, was somehow 10 to 50 times more potent (take your pick) than hydrocodone, no one seemed to question this illogical statement – because how can hydrocodone be more potent than itself? Of course, the mistake so many have made was in trying to compare “regular” Vicodin (hydrocodone with acetaminophen, aka Tylenol) to Zohydro ER (a hydrocodone with no acetaminophen and in which the medication is released over a period of time). So while the maximum recommended dosage of Vicodin can range from 40mg to 60mg depending on the type of Vicodin the maximum recommended dosage of Zohydro ER cannot exceed 50mg twice in a 24-hour period. So Zohydro ER is never 5 times let alone 10 times more potent, as cited so incorrectly by our erstwhile media.

Also another common omission by so many media outlets is that Zohydro is the first and only extended-release hydrocodone that doesn’t contain acetaminophen. This is in contrast to other opioids (even immediate release varieties) that contain either acetaminophen or some other additional ingredient. Having an opioid that contains no acetaminophen is an important tool in the pain management toolkit for people living with severe chronic pain. Of course, there’s the consideration of the abuse factor, but this pales in comparison to the estimated 6 million people living with severe chronic pain, whose voice is being drowned out by the nearly rabid and hysterical outcries of those involved with addiction issues.

As both a person living with severe chronic pain and a registered nurse, I can understand the reticence of those confronted with the issues of addiction. However I also find them unwilling to consider the needs of individuals living with intractable, severe and chronic pain. Many severe, chronic pain suffers have had to depend on opioids containing acetaminophen (done solely to “curb” the potential abuse of these same opioids) that there is a real risk of liver damage, which is why access to Zohydro ER is so critical.

Meanwhile this person wonders why no one answers the phone at the Boston Globe? How can the good people of Boston expect fair and balanced reporting if the Boston Globe only chooses to report one side of the story? Then again this is one of the main reasons so many newspapers are losing readership these days, they can’t bother to pick up the phone and, they can’t bother to report fairly both sides of the story. I guess yellow journalism is alive and well.

Finally after multiple calls and messages left to numerous individuals at the Boston Globe over many, many days — miracle of miracle the writer Milton Valencia answered his phone when I called. But when I expressed my concerns about what I believed were inaccuracies in his two articles on Zohydro ER, he suddenly had to go because he was on a deadline and anyway it didn’t really matter since he spoke with the folks at Zogenix (the makers of Zohydro ER) and they had no issues with his coverage.

You can read the two Boston Globe articles BG Judge blocks Massachusetts ban on painkiller Massachusetts and Mass. sued over restrictions on painkiller Zohydro and my letters to the editor L BG Zohydro5 and L BG Zohydro 140611b.

Nurses Answering the Call

Hurricanes, floods and earthquakes are no match for heroic nurses

By Genevieve M. Clavreul, RN, Ph.D.Working Nurse Magazine

Nurses across the country have long been at the forefront of disaster response, whether the crisis is an earthquake, hurricane or tsunami, a flood or some manmade tragedy. When disaster strikes, nurses respond at the drop of a hat, often putting their own lives on hold to offer their services and compassion to those in need.

Tales of Heroism

In 2001, nurses answered the call when terrorists flew two hijacked Boeing 767s into the Twin Towers of the World Trade Center in Manhattan. Some of the first nurses on the scene were sent to the Jacob K. Javits Convention Center, which had been converted into a makeshift 40-bed emergency hospital. At first, nurses could do little more than pour bottled water over the eyes of rescue workers.

Even when more supplies did arrive courtesy of the American Red Cross, the nurses had to cope with limited resources and nurse-patient ratios of more than 5,000 to 1.

After Hurricane Katrina in 2005, volunteer nurses streamed into the Gulf Coast, many taking unpaid leave and using vacation hours to help survivors in some of the hardest-hit areas of Louisiana, Mississippi and Texas. In response to the devastation, the California Nurses Association (CNA) formed the Registered Nurse Response Network (RNRN) to serve as a “clearinghouse” for RNs responding to disasters. The RNRN reports that some 300 nurses traveled to Gulf communities to offer aid and nursing assistance after Katrina.

Even nurses who were unable to make the trip found ways to help. One nurse answered phones at her local Red Cross. After watching television coverage of the disaster, another nurse volunteered to work in the temporary pediatric clinic that had been set up at the Houston Astrodome, treating and comforting children suffering from cuts, bruises, hunger, dehydration, disorientation and exhaustion.

Local nurses, too, put their personal needs on hold to provide much-needed assistance in the wake of Katrina. At the partially flooded Memorial Medical Center in New Orleans, where as many as 2,000 people and 200 patients were trapped without power or running water in stifling heat, nurses struggled for days to provide continuity of care and then navigated darkened stairwells and manually operated Ambu bags to transport patients to the helipad for evacuation.

International Efforts

The disasters to which American nurses have responded have not been limited to the borders of our country. In 2010, U.S. civilian nurses joined their military colleagues aboard the amphibious assault ship USS Iwo Jima for Operation Continuing Promise 2010, a four-month humanitarian deployment. Nurses provided medical assistance to Haitians after Hurricane Tomas, treating a total of 4,054 patients onboard and ashore (as well as more than 1,200 veterinary patients). As part of that operation, nurses went on to participate in seven other missions in Latin America and the Caribbean.

In 2013, Typhoon Haiyan struck the Philippines, killing more than 6,000 people and leaving almost 30,000 injured. Medical and nursing teams from hospitals and nursing associations through the U.S. raised relief funds, donated food and clothing and assembled healthcare teams to aid in disaster relief.

One team saw more than 250 patients a day, many of whom had suffered injuries that became potentially life-threatening due to the harsh conditions and delays in obtaining treatment. In addition to treating physical injuries, the healthcare teams also assisted survivors with mental health issues like anxiety, insomnia and overwhelming grief in the wake of this horrific event.

An Ethical Obligation

When a crisis strikes, people look to nurses and other medically trained professionals for information and guidance as well as care, which makes it all the more important that we learn basic disaster preparedness skills.

An article in the Australian Nursing Journal estimates that each nurse who is helpless in the face of a disaster may leave 50 or more patients in the lurch. That’s why Joanne Langan, RN, Ph.D., CNE, coauthor of the 2004 book Preparing Nurses for Disaster Management, argues that every nurse has an ethical obligation to be prepared for disasters.

Responding to a disaster doesn’t have to mean jumping on a plane at a moment’s notice. Relief efforts often need volunteers to help organize and coordinate the first responders, a role in which a nurse’s training and experience can be invaluable. Of course, nurses can also get involved by donating food, clothing, medical supplies or money to aid the victims of the disaster.

Many hospitals have established on-site disaster response teams, but nurses should also consider joining an outside organization involved in relief efforts. It’s a great way to learn more about disaster response and find opportunities to help. Below are a few places to start:

I think what nurses bring to crisis response is best summed up by a remark made by Marirose Bernard, MN, APRN, CNA-BC, then a nurse supervisor at Memorial Medical Center in New Orleans. When a reporter asked why Bernard and her colleagues didn’t leave the devastated hospital, Bernard responded, “I would never have thought of that. We were there; we were there to take care of our patients. Because we’re nurses, and that’s what nurses do.”

So, to all my fellow nurses: Keep doing what you do and have a Happy Nurses Week!

Here’s my latest article in Working Nurse Magazine —

One of nurses’ most important and underappreciated duties is advocating for our patients. While much of that advocacy takes place at the bedside, we are also in a unique position to address the larger issues that affect the practice of nursing and medicine.

The latest issue that demands our attention is the controversy over prescription opioids and the efforts of the Medical Board of California to crack down on these dangerous but necessary medications.

THE PERILS OF STATISTICS

If you listen to the fearless pundits of the Fourth Estate, deaths related to prescription drugs are a national crisis. According to the Centers for Disease Control and Prevention, 38,329 Americans died of drug overdoses in 2010 and about 60 percent of those deaths involved prescription medications, many of them opioids.

Back in 2012, the Los Angeles Times ran a four-part investigative report on the human cost of opioid abuse and the role of some physicians in overprescribing painkillers. The story reported that between 2006 and 2011, there were 3,733 deaths related to opioid use in just four Southern California counties: Los Angeles, Orange, San Diego and Ventura. That story and others like it have put pressure on the Medical Board of California to respond to the growing “epidemic.”

I put the word “epidemic” in quotes because the outcry is somewhat out of proportion to the reality. As alarming as the number of opioid-related deaths sounds in isolation, the L.A. Times report failed to contextualize that statistic in terms of the combined population of those four counties (16.9 million as of July 2011), the population of California as a whole (37.7 million) or the number of deaths due to other causes during the same period. For example, according to the California Highway Patrol, car crashes killed 18,416 Californians between 2006 and 2011: almost five times the death toll of the headline-grabbing opioid menace.

PSE AND THE METH EPIDEMIC

I don’t mean to diminish the significance of those deaths or suggest that there isn’t a problem, but it’s important not to let alarmism triumph over common sense. While the number of collision-related deaths may indicate a need for better traffic safety, no one is seriously suggesting closing our freeways or restricting how far commuters are allowed to drive!

Unfortunately, when it comes to drugs, such overreaction is the rule rather than the exception. For instance, many of us are familiar with the federal Combat Methamphetamine Epidemic Act of 2005 (CMEA), which sought to stem the rise of methamphetamine abuse by restricting the sale of products containing the nasal decongestant pseudoephedrine (PSE).

PSE is not a prescription drug in most states, but the CMEA limited how much PSE a customer could buy at one time, mandated behind-the-counter placement in stores, required photo identification for purchase and forced sellers to maintain logbooks of sales and customer information. Those measures have had little impact on the meth epidemic. At a conference this February, DEA Office of Diversion Control Deputy Assistant Administrator Joseph Rannazzisi admitted that “NEITHER of these systems [tracking or rescheduling PSE] will have ANY impact on methamphetamine availability in the United States.” [emphasis in the original]. In short, these restrictions  have not curbed the meth supply, but have added a considerable bookkeeping burden for retailers while inconveniencing millions of cold and allergy sufferers.

The effects of the state medical board’s response to the outrage over opioid-related deaths may be far worse. Some of the suggestions I heard at a recent meeting of the board’s Prescribing Task Force left me wanting to tear out my hair in frustration.
the role of alcohol

California’s medical community has good reason to be embarrassed by the L.A. Times expose, which linked a substantial number of overdose deaths in Southern California to a surprisingly small number of doctors.

The story also raised serious questions about the medical board’s effectiveness in responding to complaints about excessive or reckless prescriptions. The board seldom suspends a doctor’s prescribing authority even if he or she is being actively investigated or has already been disciplined for reckless prescribing.

Given all that, you might expect that the Prescribing Task Force’s focus would be on improving the medical board’s oversight of its own members. Instead, I listened to hour after hour of experts proposing new restrictions on patients. The suggestions ranged from requiring patients to sign a contract with their physician prior to receiving prescription opioids to forcing all patients to submit to pill counts and random urine tests. Such measures would be tantamount to treating patients like criminals!

There were more sensible proposals calling for greater patient education, but overall, I was dismayed by the lack of clear-headed perspective on the issues involved. For example, one expert pontificated at length about the evils of opioid abuse without once mentioning the role of alcohol in many painkiller overdose cases. When I asked him about it, he replied that he would touch on that point at the end of his presentation, suggesting that he considered alcohol a trivial footnote rather than a significant contributing factor in many overdose deaths.

PUTTING PATIENTS LAST?

As a nurse and as one of the estimated 100 million Americans living with some degree of chronic pain, I am well aware of both the power and the dangers of opioid painkillers. There’s no argument that opioids carry a high potential for abuse and can kill if misused.

However, I’ve also witnessed the consequences of overzealous protocols that prevent patients from getting needed medication. If you suffer chronic pain, draconian limits on how much painkiller you’re allowed do not protect you; they just reduce your ability to function and increase the chances that you’ll find some other way to self-medicate — possibly with lethal consequences.

Tools like pill counting or contracts may be appropriate in certain cases, but imposing such restrictions on all patients would only have a chilling effect on the provider-patient relationship. If our approach to patients defaults to suspicion and mistrust, we only discourage our patients from communicating openly with us about issues like abuse and addiction.
comprehensive approach

So, what should be done? A better solution would include all of the following:

  • Improved education for patients about the dangers and proper use of opioids, including the risk of adverse interactions with alcohol or other drugs.
  • Better educating physicians and their healthcare teams about the signs of opioid abuse, including how to recognize potential risk factors like addictive personalities.
  • Fully implementing a real-time prescription drug monitoring program that can flag suspected prescription shoppers and physicians who may be recklessly prescribing opioids or running “pill mills.” California’s CURES (Controlled Substance Utilization Review and Evaluation System) could be but currently isn’t used for that purpose due to a lack of resources and interest.
  • More effective sanctions for doctors whose prescription history suggests a pattern of reckless or inappropriate prescribing.
  • Finding and funding alternative treatments for chronic pain and conditions that cause it. If you remove the source of the pain, you also remove the need to treat it with opioids.

Obviously, many of these are long-term solutions. In the short term, it’s important that nurses get involved in the debate. The Prescribing Task Force’s next meeting is in May. (See www.mbc.ca.gov for a schedule.) The meetings are open to the public and I urge readers to attend and participate.

This is an issue that directly affects many of us, our loved ones and our patients. We should not sit idly by while the medical community devises quick-fix solutions that may ultimately do more harm than good.

Genevieve Clavreul’s earlier article on this topic, “The Great Opioid Debate of 2012,” was published in WN127, Sept. 3, 2012.

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Scott Glover and Lisa Girion, “Dying for Relief: A Times Investigation,” Los Angeles Times:

Part 1 (“Legal Drugs, Deadly Outcomes,” 11 Nov. 2012)

Part 2 (“Reckless Prescribing, Lost Lives,” 9 Dec. 2012)

Part 3 (“Rogue Pharmacists Feed Addiction,” 20 Dec. 2012)

Part 4 (“Unused Tool Could Help State Flag Deadly Doctors,” 30 Dec. 2012)

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CDC, “Drug Overdose in the United States: Fact Sheet,” last updated 10 February 2014. The fact sheet says 60 percent of 2010 overdose deaths were pharmaceuticals, of which 75 percent involved opioids and 30 percent involved benzodiazepines.

Physicians for Responsible Opioid Prescribing, “Cautious, Evidence-Based Opioid Prescribing.”

The American Academy of Pain Management, cites 100 million chronic pain sufferers in America, per Institute of Medicine Report, “Relieving Pain in America.”

Transforming Prevention, Care, Education and Research (Washington, D.C.: The National Academies Press, 2011.

What to expect and when you need a lawyer

By Genevieve M. Clavreul, RN, Ph.D.

The mere mention of an investigation by the California Board of Registered Nursing (BRN) can strike fear into the heart of any nurse, and for good reason. A BRN investigation can turn your life upside down and even end your career.

With that in mind, I thought it would be worthwhile to explain what you can expect if you become the target of such an investigation.
by the numbers. Nurses can take some comfort in knowing that only a small percentage of RNs wind up in the BRN’s investigative sights each year.

Look at the Numbers

According to the BRN, there were 392,458 actively licensed RNs in California in September 2013. During the 2013 fiscal year (July 2012 through June 2013), the BRN’s Complaint Intake office recorded a total of 8,330 new cases, of which 7,714 were assigned for investigation.

The majority of last year’s new investigations — more than two-thirds — were initiated because the BRN learned that a nurse had been arrested for or convicted of a felony or misdemeanor related to his or her nursing duties or qualifications. The most common offense was driving under the influence (DUI).

Only 2,876 BRN complaints were filed by consumers in fiscal 2013 and 508 of those complaints were closed without an investigation. That means only about 0.6 percent of California RNs — one in every 163 nurses — faced a BRN investigation last year due to a consumer complaint.

First Steps

Let’s imagine that worse comes to worse and someone files a complaint against you. The BRN’s first step is to review the complaint to determine if it falls within the board’s jurisdiction. If not, the complainant may be referred to a more appropriate agency, but the case is considered closed as far as the BRN is concerned.

If the complaint does fall within the board’s purview, the next step is to determine if there is reason to refer you to the Diversion Program. This is a voluntary, confidential program for nurses struggling with mental illness or problems with drugs or alcohol. Obviously, that isn’t relevant in many cases and even if it is, the BRN may not offer you the option. Also, you can’t practice while you’re enrolled, so while the program might let you keep your license, you will probably lose your job.

If you aren’t offered that option or you decline, the board assigns the complaint for further investigation. Depending on the nature of the allegations, a complaint might be investigated by BRN staff, the Division of Investigation of the California Department of Consumer Affairs (of which the BRN is a part) or an outside investigator.
harsh questioning

Make no mistake — a BRN investigation can become a nerve-wracking examination of your professional and private life that makes a TSA strip search look like a friendly pat on the back.

Adding to the stress is the fact that investigators aren’t obliged to tell you exactly what they’re after or even the full details of the complaint. You won’t usually know who the complainant is or what they said, which can leave you scrambling to defend yourself without really understanding what kind of trouble you’re in.

BRN investigations are considered administrative actions, not criminal investigations, so many of the legal tidbits you’ve gleaned from watching TV dramas like “Law and Order” don’t apply here. Nevertheless, there are two rules that do apply: You have the right to remain silent and anything you say is likely to be used against you!

Call Your Lawyer

You are allowed legal counsel when speaking to the BRN investigators, and if you’re facing an investigation, hiring an attorney may be a wise move. Unfortunately, it can also be expensive. Many malpractice insurance policies don’t protect you in the event of a board complaint or will impose caps on how much the insurer will pay to assist in your defense. Still, if the investigation results in a formal accusation, your entire nursing career may be on the line, so the cost might well be worth it.

If you don’t know how to find a lawyer with expertise in this area of law, the American Association of Nurse Attorneys (www.taana.org) may be able to help. This is an association comprised of RNs who are also attorneys, many of whom have experience representing nurses in cases like these and understand both the legal and professional issues involved.

The Formal Investigation

An investigation is just that: examining the evidence related to a complaint to determine if it has any substance. Not all investigations result in an accusation, much less disciplinary action. Sometimes, investigators conclude that the allegations were false or at least that there is insufficient evidence to substantiate them. In other instances, the board might decide the allegations are substantiated, but opt to let you go with a citation and a fine.

If you’re not so fortunate, the board’s next step is to issue a formal accusation that you have violated the Nursing Practice Act. This accusation is public record and anyone can look it up on BreEZe or the BRN website. In most cases, the accusation will be followed by an administrative hearing, which is like a trial.

If you haven’t already hired a lawyer by this point, you should seriously consider doing so. Administrative hearings have their own terminology, rules and procedures; a simple misunderstanding could be career-ending. If you don’t promptly file a notice of defense after receiving the accusation — in which case the board will assume you’re forfeiting your right to a hearing — or if the board rules against you, you may be kissing your license goodbye. Depending on the allegations, you might even face criminal charges.

Keeping the BRN Fair

We like to think that the BRN represents nurses’ interests, so ending up on the receiving end of the board’s suspicion can feel like a betrayal. However, we should keep in mind that the BRN is not in the business of protecting RNs — it’s in the business of protecting the public from RNs!

If the BRN has reason to believe a nurse has stepped out of line, the public and our elected officials have every right to demand that the board act swiftly and firmly to investigate and correct the situation.

That doesn’t mean that nurses have to stand by helplessly or be railroaded. By educating ourselves on the BRN’s policies and disciplinary procedures, we can exert our influence to ensure that the board acts fairly and justly. BRN meetings, including the meetings of the Diversion/Discipline Committee, are open to the public and allow for public comment on any issue relevant to the committee’s business, even if the item isn’t on the agenda.  (You can find a schedule of meetings here.)

Another option, and one I always recommend for nurses, is to get involved with the legislative process. Remember, the BRN’s function is to enforce state law and regulations. If you feel those rules are unjust, it only makes sense to address your complaints to the lawmakers with the power to change them — or consider running for office yourself.

 

With more and more dire reports coming out about California’s growing nursing shortage, you would assume that our state desperately needs nurses. Nearly every day, my email inbox is besieged with messages advertising temporary and permanent nursing positions and a cursory search on one of the national nursing job boards returns more than 1,000 job openings.

However, if you read the forums on those same job boards, you’ll find post after post from nurses — mostly new graduates — complaining that they’re unable to find a job in their chosen profession. To hear them tell it, there are too many nurses vying for too few jobs.

So, what’s going on? Is there a nursing shortage or is there really a nursing glut? The answer is yes and yes. Confused? Read on.

Failing Grade
According to the U.S. Nurse Workforce Report Card and Shortage Forecast, published in the American Journal of Medical Quality in 2012, over the next two decades, the demand for nurses will greatly outpace the supply.

Even states that currently have good nurse-patient ratios, like Massachusetts, are expected to slip to mediocre by 2030, so you can guess what that means for our fair state, which is already near the bottom of the heap.

California’s nurse-to-population ratio has ranked a dismal 48th in the nation for the past 10 years. In 2013, California had an estimated 657 RNs for every 100,000 population, well below the national average of 874 RNs per 100,000. The Nurse Workforce Report Card gave California’s RN supply a “D” grade and projects that by 2030, we will be more than 193,000 nurses short of our nursing needs. (So much for the wishful thinking 10 years ago that legally mandated nurse-patient ratios would somehow resolve our nursing shortage!)

By now, we’ve all heard the reasons for the predicted nursing shortage: an aging population that will need more care, more people having access to care due to the ACA and an aging workforce that’s not being replaced fast enough. It paints a worrisome picture.

Unprepared For Nursing School
Between 2001 and 2010, the number of people enrolling in nursing school here in California increased dramatically, leading to predictions that the state’s total nursing workforce would grow by about 60 percent between now and 2030. Currently, the reality looks much less rosy. According to a recent report prepared for the BRN by the Philip R. Lee Institute for Health Policy Studies and School of Nursing at UCSF, nursing school graduation rates for the past few years have been lower than expected and growth has been slow. Only 195 more nurses graduated in the 2012–2013 academic year than in 2011–2012, an increase of only 1.8 percent. The report predicts that graduations for the 2015–2016 school year will actually drop below the 2010–2011 level.

The number of licenses granted to foreign-educated and out-of-state nurses is also down. While fewer California RNs are leaving the state for greener pastures, fewer nurses are moving to California. As a result, the report forecasts that even in a best-case scenario, California’s RN supply will grow only about 10 percent by 2030 — not nearly enough.

The UCSF report recommends “growing our RN programs a bit more,” but that may be easier said than done. In California, many students are ill-prepared to enter a nursing program due to a lack of prerequisites like microbiology, statistics or psychology. Having to play catch-up will delay admission.

Students who do enter nursing programs may face a shortage of instructors. Quality nursing faculty is already in short supply and that shortfall is also getting worse.

New Grad “Catch-22”
If all that is true, why are so many newly minted RNs (both ADN-prepared and those with BSNs) having a hard time finding work? And why do many chief nursing officers in California believe there are more than enough RNs to meet current requirements?

First, keep in mind that the various estimates and projections of nursing shortages are for the state as a whole. California is a big state and even if you live in a county that’s been designated as a registered nurse shortage area (like Los Angeles County), that doesn’t mean you can just stroll over to your neighborhood hospital and get a job tomorrow.

Healthcare provider shortages are usually most severe in poor or rural areas where new grads may not think — or want — to look for jobs. Hospitals in more prosperous areas often have plenty of nurses and lots of applicants and can therefore be pickier about education and experience.

One of the most common demands is acute care experience, something in which far too many new grads are sorely lacking. Getting enough experience to satisfy a hospital recruiter may require some creative solutions on the part of new grads.

Back in the “good old days,” a new nurse could gather a plethora of real-world experience by working as a travel nurse, but today, most travel nurse services require at least two years of hospital experience prior to placement.

Adding to the frustration of the new grad looking for work is the fact that many current RNs are still putting off retirement. The UCSF report confirms that employment rates are higher among older RNs, many of whom continue to practice because they can’t afford to retire. That means new grads are competing for jobs with older nurses who have far more clinical experience.

The Spectrum of Staff Experience
While some parts of California do have a nursing glut right now, hospital nursing directors and chief nursing officers need to recognize that in many cases, the current honeymoon won’t last. Eventually, older nurses will leave the nursing workforce, either because the economy has improved enough to rebuild their retirement nest eggs or for health reasons.

The vacuum left by those departures will need to be filled — in all likelihood, by the same new grads being turned away now. Even without an overall RN shortage, such “backfilling” is critical to maintaining a healthy and vibrant nursing workforce.

During my tenure as a director of nursing, I worked hard to ensure that our hospital’s nursing team was as diverse as possible. A critical component of that diversity was having a wide spectrum of experience, from new nurses to seasoned veterans.

In that way, our experienced nurses could mentor the new grads, who would in turn bring a level of enthusiasm and cutting-edge knowledge that benefited their more experienced colleagues. It was a win-win situation.

What’s the outlook for new grads? There are nursing jobs to be had, but in the short term, finding one without acute care experience will continue to be a challenge. That leaves the new grad with a choice: If you don’t want to wait around for your more experienced colleagues to retire, you’ll need to either find ways to build your clinical experience or be willing to look for jobs in areas off the beaten path.

Few will deny that California’s nursing population needs to grow or that there are real obstacles to that growth that need to be addressed, such as the shortage of nursing faculty. However, it’s important to recognize that nursing shortages (or surpluses) are not cut and dried. The future of nursing in California is in our hands.

A Tale of Rabies

The only hope was a radical experimental protocol

By Genevieve M. Clavreul, RN, Ph.D.

We called him Peanut: a small, fragile boy who was admitted to our pediatric intensive care unit (PICU) at Columbus Medical Center in Columbus, Ga., in the late ‘70s with an infection we would later diagnosis as rabies.

Although rabies is no longer as common as it used to be in the U.S. — an aggressive public health campaign has reduced the number of confirmed cases from almost 6,000 a year in 1979 to fewer than three in 2010 — it is still a lethal disease that can test caregivers to their limits. When Peanut came to us three decades ago, it was an almost certain death sentence if not treated in time.

GRIM DIAGNOSIS
No one was ever quite sure how a little boy in one of Georgia’s larger cities had come to be bitten by a rabid animal. The most common carriers of rabies in western Georgia were raccoons, skunks, foxes and bats — not your typical urban fauna. Peanut’s parents had brought him to the emergency room with no idea of the nature of his illness and his symptoms had puzzled the ER physicians. When he was transferred to our PICU, the doctors were still unsure what was wrong.

Caring for Peanut presented some unique challenges. He was just a toddler and his age and condition limited his ability to communicate with the staff. We used a combination of sign language, pantomime and pictograms to quiz him on how he felt, where he had pain and so forth. His parents did their best to help, but they were as flummoxed by his condition as we were.

Rabies is a viral infection with three clinical stages. Peanut was admitted during the prodromal phase, which may include several days of flu-like symptoms. During the second stage, known as the excitation or “furious” phase, the patient may present with the symptoms commonly associated with rabies, such as dilated or rolling eyes, tachycardia, hyperventilation and hydrophobia. If the patient survives this phase, the disease moves into its third and final stage with the progressive onset of paralysis, stupor, coma and death.

Days passed as Peanut’s physician ordered test after test to whittle down the list of suspects. Then, Peanut presented with two of the unmistakable signs of rabies: a “locked jaw” and excessive salivating. The evening when I came on shift and saw the latter symptom made me and my team dread the impending diagnosis. Reviewing the likely outcomes left us on the brink of despair. Survival from rabies at that stage was so rare that it was not even included in the list of outcomes.

Our PICU team was by no means unaccustomed to death, but nothing in Peanut’s original symptoms had prepared us or his family for such a grim prognosis. How were we going to inform Peanut’s parents that their son’s most likely outcome was death?

THE EXPERIMENT
Later that day, our unit’s doctors and nurses held a meeting to discuss Peanut’s case. Since his condition was so advanced, neither rabies vaccine nor antiserum was an option. Instead, we decided to place him in an induced paralytic state, use supportive therapy to get him through the worst of the symptoms and hope for the best. (This was decades before the development of the Milwaukee protocol.)

After many telephone calls and much research on different paralytic drugs, our pediatric chief of staff settled on Pavulon, the brand name for Pancuronium bromide, a non-depolarizing curare-mimetic muscle relaxant. There was just one hurdle: Pavulon was not approved for pediatric patients and this off-label use required the approval of both the manufacturer and the FDA. Fortunately, after much finagling and promises to carefully document everything, our team got the necessary authorizations and set about developing a protocol for Peanut.

Since this was uncharted territory, we kept the protocol as simple as possible. We titrated the muscle relaxant until we discovered the minimum amount of Pavulon needed to paralyze Peanut. Doing so left him completely aware but unable to move, which was the only way to keep him from fighting the vent. (In those days, we had no inline suction and lacked the sophisticated equipment now available to anchor and stabilize an endotracheal tube.)

Our chief of staff then wrote a standing order to administer that same amount of Pavulon whenever Peanut exhibited any signs of movement. To help us monitor Peanut’s sedation level, we came up with an ingenious system of strings and mobiles that would move with his slightest motion. I can’t remember whose idea this was or where it originated, but it was wonderfully simple and very effective.

After many weeks, we were able to wean our patient off both the Pavulon and the vent. During this period, poor little Peanut could barely move his stiffened muscles, but every time he reached out for something or took a step, however stiffly or woodenly, we saw it as one more sign of a hard-won recovery from a devastating disease.

VITAL LESSONS
Peanut’s case was highly inspirational to those of us in the PICU, showing us that if we came together as a team, we could move mountains. He also taught me an important lesson: No matter what condition or state of mind patients may be in, they can still tell you a great deal about how the nurses interact with their patients.

As Peanut emerged from his induced paralysis, I noticed that there was one nurse on our team around whom he was visibly apprehensive. Later, when he was again able to move, he would run screaming from her into the arms of his parents or any other nurse who happened to be nearby.

At first, I couldn’t understand why Peanut would so be afraid of that particular nurse, who hadn’t subjected him to any procedure that hadn’t also been performed by every other nurse in our unit. It wasn’t until much later that I discovered Peanut had good reason to fear that nurse, who had a cruel streak that would eventually lead to her dismissal from our unit. She didn’t have the temperament for the PICU and Peanut was the first to catch on. I wish I had listened sooner.

HOPING FOR THE BEST
Eventually, Peanut was stable enough to be released and return home. I lost track of this spunky little patient as my life and career handed me other challenges. I’d like to think that he was one of the lucky few to survive his encounter with rabies, although the odds were against it.

As of 2008, there were only three known unvaccinated rabies survivors in the United States. Peanut might have been one of those three; I certainly hope so. I do know that I and the PICU staff at Columbus did everything in our power to make that outcome possible.