Premature (Preemie) Child of Cocaine Addicted Mother Survives Abortion. Physician Order: Leave To Die?

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Summary: The premature birth of a child under normal
circumstances requires highly skilled nursing and medical
care if the child is to survive. The birth of a premature child
to a known Cocaine addicted mother greatly increased the risks
of mortality. In this case, a child intended to be aborted is born alive.
When the physician orders that the child be to left to die,
it miraculously survives on its own. Were the nurses liable for
"following orders?"

The pregnant woman had an active history of Cocaine and
Marijuana substance abuse during her pregnancy. Her
admission to the hospital was for the specific purpose of an
abortion. Her addiction would make her a high risk obstetrics
patient.

"Abuse of alcohol and other drugs is associated with low birth
weight and preterm birth, but relatively few pregnant women
engage in drug abuse. The recent "epidemic" of cocaine use in
the United States did not have a large effect on overall rates of
low birth weight or preterm birth and may have been confined
to local areas.16 However, some individual mothers and infants
do suffer from the effects of drug abuse. Many women who
desire to enter drug treatment programs are turned away because
programs for drug-abusing pregnant women are generally
unavailable.17"2

The mother's labor would progress and in the absence of the
physician, the fetus was delivered by the nurses.

"Premature Birth and Low Birth Weight Infants

Low birth weight (LBW - under 2500 grams) occurs in seven
percent of births in the United States, and is associated with over
half of infant deaths. Risk factors for low birth weight include
late entry into prenatal care, low socioeconomic status, poor
reproductive history, poor weight gain, smoking, and substance
abuse.

Very low birth weight (VLBW) and extreme prematurity (weight
under 1500 grams) occurs in fewer than one percent of pregnancies
but consumes enormous financial and human resources."3

In the State of Tennessee, a child inadvertently born during an
abortion is afforded special protections. A child born in this
manner is entitled to treatment as if it were a typical premature
child. A child acknowledged to have born under these conditions would
have received supportive measures as required by law.

The premature following delivery would intubate the child and begin
life supportive measures to keep the child alive.

The physician would soon arrive. He noted that the child weighed
less than 1.5 lbs at birth and commented that the chances of
survival were poor. On discovering the child had been delivered,
he would order extubation after a brief examination.

In essence, he ordered cessation of all life supportive measures to
the premature infant. The physician's orders were to leave the
child to die.

"Which premature infants are so malformed, sick, or immature that
newborn intensive care (neonatal intensive care) should not be
administered? The potential benefits of intensive care--expressed
in terms of total years of life or total disability-free years that may
be gained from use of intensive care--are greater for these infants
than for older children or adults. However, the costs--both human
and material--are also greater, particularly for infants
(and their families) who survive with severe lifelong handicaps.

Decisions about whether to provide neonatal intensive care to
marginally viable newborns are particularly difficult, in part
because the infants are unable to speak for themselves."4

The premature followed the orders of the physician. They extubated
the child and prepared for the death pronouncement. The child
would continue to breath on its own after extubation for over an
hour.

At that point, the child would be transferred to another facility.
A Neonatologist would attend to the child who would be left with mild
hearing and speech impairments. These were presumably a direct
result of oxygen deprivation to the brain. During the time period
following extubation and until the transfer/admission the child had
been breathing on its own.

A lawsuit would be filed on behalf of the child against the
Delivering physician, the hospital and the attending nurses.
Claims included negligence, medical malpractice, battery, and
outrageous conduct. It alleged that the providers were in violation
of the Tennessee statute outlining the right to medical
treatment of an infant prematurely born during an abortion.

There was controversy over which protections the child was
entitled to. Although it was clearly born premature and without the
presence of a physician, it had been admitted for the purpose of
abortion.

The initial court noted that in this circumstance the child had not
been expected to live following delivery. It found that the nursing
actions under the direction of the physician were consistent with
their interpretation of the law.

In a voluntary action, the premature were removed from the action by
the plaintiff. The court then called for a directed verdict in favor of
the defendant physician.

The plaintiff appealed:

Questions to be answered:

1. Could the premature be held liable for negligence because they
followed the physician's orders to extubate the child.

2. Was the child protected under the legislation governing children
born during abortion attempts.

The appeals court in reviewing the proceedings noted the
following:

In the initial trial, the court clearly agreed that because the child
was born prematurely. There was no question that regular
protections afforded preemies were appropriate. The confusion
was over protections to fetuses delivered during the "act" of an
abortion.

It agreed that because the pregnant mother had been admitted for
an abortion, the physician and premature acted appropriately in
withholding life support. It did not however, agree that the child
was entitled to the special protections afforded to preemies born in
attempted abortions. This is mostly likely due to the fact that the
physician was not present during the delivery or actively
performing an abortion at the time.

The plaintiff's attorneys had argued that care was negligently
withheld. The appeals court noted that it did not however, produce
expert testimony to support that argument. No relevant caselaw
was presented to support the plaintiff's position.

In light of the lack of testimony by the plaintiff, the appeals court
affirmed the judgement of the lower court.

Could the case have gone differently if expert testimony and
previous precedents had been presented? Yes! Definite harm most
may have come to the child due to the lack of supportive measures.
It was fortunate for the premature that the court ruled against
negligence.

premature clearly have a duty to the patient when there is a question
of whether or not it is appropriate to carry out a physician's orders.
When faced with this situation, it is best to consult with another
nurse or a nursing supervisor before proceeding.

If there is still a question and if time allows, the chain of command
established by a facility must be followed. The benefit of this to
the nurse, is that a second opinion and so on is obtained. If the
orders turn out not to be appropriate, it is then not simply a nurse's
judgement or word against that of the physician.

Related link Sections:

Cocaine, Substance Abuse & Drug Addiction Links
http://www.nursefriendly.com/nursing/directpatientcare/substance.abuse.drug.a...

Direct Patient Care Links
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Drug Addiction, Substance Abuse Nursing Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/addiction.html

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Obstetric Nurses on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/obstetric.html

Premature Infants, Low Birth Weight Babies
http://www.nursefriendly.com/nursing/directpatientcare/obstetrics/premature.i...

Sources:

1. 36 RRNL 8 (January 1996)

2. Shiono, Patricia H. & Behrman, Richard E. Low Birth Weight: Analysis and Recommendations. The Future of Children Vol. 5 No. 1 Spring 1995. Retrieved July 26, 1999 from the World Wide Web: http://www.futureofchildren.org/LBW/02LBWANA.htm

3. The Oxford Health Plans Foundation. No Date Given. Premature Birth and Low Birth Weight Infants. Retrieved July 25, 1999 from the World Wide Web: http://www.oxhpfoundation.org/rfp_birth.html

4. Tyson, Jon. The Future of Children. Evidence-Based Ethics and the Care of Premature Infants. Vol. 5 No. 1. Spring 1995. Retrieved July 25, 1999 from the World Wide Web: http://www.futureofchildren.org/LBW/13LBWTYS.htm

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Nursefriendly, Inc. A New Jersey Corporation.
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856-415-9617, (fax) 415-9618

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Good Samaritan Laws & Acts. Do They Cover Nurses Volunteering Nursing Care When A Citizen Goes Anaphylactic.

See also: Medical, Legal Nurse Consultants, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

To receive each case and supporting resources by E-mail weekly,
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Summary:  "Off-duty" healthcare professionals rendering
Emergency aid are in most cases "covered" by the Good
Samaritan Acts.  These are laws enacted in each state
that provide some degree of immunity from liability for
good faith efforts in giving emergency care.  In this
case, a nurse and physician were sued for providing
assistance in a volunteer function at a "first-aid" station.
Good Samaritan "immunity" was not recognized by the
courts.

A nurse, physician and several others volunteered to help
out with a first-aid station at a food festival being held locally.
 During the festivities one attendee would suffer an anaphylactic
attack.

The man had a known allergy to fish and helped himself to a
"gumbo" mix that contained the allergen.  He proceeded to experience
an anaphylactic allergic reaction.  The event "first aid squad" was
notified only of a "problem" and the person's location.

"Anaphylactic Shock

is the most severe form of allergy which is a medical emergency,
is a type I reaction in Gell And Coombs Classification .An often
severe and sometimes fatal systemic reaction in a susceptible
individual upon exposure to a specific antigen (as wasp venom
or penicillin) after previous sensitization that is characterized
especially by respiratory symptoms, fainting, itching, urticaria,
swelling of the throat or other mucous membranes and a sudden
decline in blood pressure."2

Of those present, all but a nurse remained at the station.  With the
physician and others on the way to assist the victim, clearly someone
had to stay at the station in case there were other emergencies.  The
question would arise of whether or not their actions were covered
under existing Good Samaritan Laws.  A key consideration is whether
or not a legal "duty to assist" the victim was created when the
responsibility to "volunteer" was accepted.

"Flynn v. United States, 681 F. Supp. 1500, 1506 (D. Utah 1988),
modified in part, 902 F.2d 1524 (10th Cir. 1990). Good Samaritan
laws responded to the common law rule that made one liable for
negligently rendering voluntary emergency assistance by extending
immunity from suit, thereby encouraging humanitarian acts by
licensed medical providers."3

Arriving on the scene, not knowing what to expect, they found
the person symptomatic, still conscious and standing on his own.
He indicated that he'd had a reaction and was in need of "a shot."

"Symptoms of anaphylactic shock include dizziness, loss of
consiousness, labored breathing, swelling of the tongue and
breathing tubes, blueness of the skin, low blood pressure, and
death bronchospasm"1

The physician recognizing the anaphylactic nature of the situation
requested one of the others obtain "epinephrine," while she stayed
with the patient.

When the other member of the squad returned with a single "Epi pen."
 The physician administered a dose.  The patient claimed to not have
obtained any relief.  A second shot was requested.  The pen was a
single dose unit only.  Having already used the available dose, the
physician explained it would be nearly empty.  There was no other
immediate source of epinephrine available at the time.  Unable to
offer an alternative, the physician gave the patient a second shot with
the same injector hoping it might still contain "some" medication.

Again the patient did not obtain relief.  With symptoms persisting,
the patient's condition deteriorated.  At this point an ambulance was
on the way, the nurse had been relieved at the station and came up
to assist, still unaware of what the problem had been.

When she came upon the patient, the best she could do was stay
with him until the emergency medical personnel arrived.  The
patient would complain of increasing shortness of breath.  En route
to the hospital, he would slip into a coma.  He would die the next day.

A lawsuit was filed naming both the physician and the nurse alleging
a "wrongful death."  Both the nurse and physician fought this in court.
 In the initial trial, the complaint was dismissed.

They argued for protection under the Good Samaritan Acts of the state.
  This legislation was enacted to encourage health professionals to
render aid at the roadside.  Previously, professionals had and still do
hesitate to assist for fear of being sued by the injured party.

"Because of the pervasive myth of liability in the medical professions,
most states have enacted some form of Good Samaritan law prohibiting
a patient from suing a physician or other health care professional for
injuries from a Good Samaritan act. To trigger the protection of such
an act, two conditions must be satisfied: it must be a volunteer act, and
the actions must be a good-faith effort to help. Displacing a neck fracture
in an effort to do rescue breathing might be malpractice in the Emergency
Room, but it is not bad faith on the roadside."4

While a Good Samaritan Act may protect you in state-specific circumstances
from being found and held liable, it will not protect you (nor will an
employer's malpractice insurance policy) from being sued in the first place.

In most states there is no obligation for a bystander to render aid or
legislation to penalize those that do not decide to get involved.
Minnesota, Vermont and Wisconsin are exceptions to this rule.
Minnesota statutes follow:

"A person at the scene of an emergency who knows that another person
is exposed to or has suffered grave physical harm shall, to the extent
that the person can do so without danger or peril to self or others, give
reasonable assistance to the exposed person. Reasonable assistance
may include obtaining or attempting to obtain aid from law enforcement
or medical personnel. A person who violates this subdivision is guilty
of a petty misdemeanor. "5

A common thread in each of the Good Samaritan laws is that no
immunity will be afforded for specific exceptions.

"The most commonly stated exception to immunity is for conduct that
is willful and wanton. Many jurisdictions also exclude other categories
of conduct, such as conduct that is grossly negligent, reckless, malicious,
in bad faith, fraudulent, or intentionally tortious or that is a knowing
violation of law. A few even included ordinary negligence, which arguably
negates the protection afforded."6

In the state of Rhode Island, in which this event occurred, there are
no specific laws requiring that a bystander give assistance.

Interestingly, immunity by the state laws is granted in the following
which do not specify volunteer medical and first aid activities.

"Rhode Island law also grants immunity from civil damages to:

(1) Persons rendering service as, or assisting, a manager, coach, instructor,
umpire, referee or official in certain interscholastic or intramural
sports programs;

(2) Any uncompensated person voluntarily serving as or assisting a
manager, coach, instructor, umpire, referee or official in a youth
sports program organized and conducted by or under the auspices
of a nonprofit corporation; or

(3) Directors, officers, trustees or employees of any nonprofit
organization, authorized to do business in the state, that organizes,
conducts or sponsors a youth sports program.208"6

It is debatable whether the initial trial led to a dismissal on grounds
of protection under existing Good Samaritan laws, or simply a lack
of evidence to prove negligence.  Of these, the latter is more likely.

With the complaint initially dismissed, the patient's estate appealed.

Questions to be answered.

1. In rendering care to the patient in a state of anaphylaxis, did
both the nurse and physician perform to the best of their abilities
with the resources available to them.

2. In rendering emergency aid to the patient, were they covered by
the state's existing "Good Samaritan" laws.

The plaintiff's attorneys would argue that negligence had been
a factor in the patient's death.  They accused the physician and
nurse of arriving on the scene "unprepared" to deal with the situation.

Interestingly, the plaintiff could offer no expert witness testimony
to support this.

In deciding the second question, the court explicitly stated that
"it assumed the defendants were not covered under Good Samaritan Laws."

This is alarming in that if the plaintiff had been able to produce
sufficient expert testimony to prove negligence, the nurse and
physician may well have been held liable.

In light of these circumstances,  the ruling of the lower court was
affirmed.

It sends a frightening message to nurses, medical and health care
personnel who chose to "volunteer" their expertise in times of need.
Some state laws do require action in specific circumstances:

It is unclear whether this opinion was offered because the assistance
was "organized."  Is an exception made to the Good Samaritan Acts
for First Aid Squads and Organized Emergency Medical Personnel
regardless of whether or not they charge the patient for their services?

Troubling questions for the individual when deciding whether or not
to render aid.  The answers and exceptions are defined in individual
state laws that vary widely.

Many nurses rely on malpractice insurance provided by their
employers to cover them at work.  It is highly unlikely that such
a policy would cover them while performing volunteer duties.

If you accept responsibility to perform expected duties either on
a paid or volunteer basis, for a profit or non-profit organization, you
may not be covered under otherwise applicable Good Samaritan Statutes.
If you chose to protect yourself by carrying malpractice insurance
policy, it would be wise to make sure this coverage is specifically included.

Related link Sections:

Direct Patient Care Links
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Good Samaritan Laws & Acts:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/good.samaritan.laws.acts.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Sources:

1. 38 RRNL 4 (September 1997)

2. Health on The Net Foundation. July 2, 1998.  HON Allergy Glossary Anaphylactic Shock. Retrieved July 18, 1999 from the World Wide Web:  http://wolfgang.hcuge.ch/Library/Theme/Allergy/Glossary/shock.html

3. Utah State Courts. Filed November 14, 1997.  Hirpa v. IHC Hospitals, Inc., No. 960180.  Retrieved July 18, 1999 from the World Wide Web:  http://courtlink.utcourts.gov/opinions/supopin/hirpa.htm

4. Law and the Physician Homepage.  No Date Given.  Good Samaritan Laws. Retrieved July 18, 1999 from the World Wide Web:   http://plague.law.umkc.edu/Xfiles/x894.htm

5. LawGuide.  1998.  Minnesota Good Samaritan Law.  Retrieved July 18, 1999 from the World Wide Web:  http://www.lawstreet.com/lawguide/sigsgomn.HTML

6. Carter-Yamauchi, Charlotte A. 1996.  Volunteerism - A Risky Business? Retrieved July 18, 1999 from the World Wide Web:  http://www.hawaii.gov/lrb/vol/volchp3.html
 

Sheriff to serve 100 days, lose license for retaliating against nurses - Mywesttexas.com: Top Stories

Winkler County Sheriff Roberts L. Roberts will serve 100 days in jail and lose his Texas Peace Officers License for retaliating against two whistleblower nurses, a judge order Tuesday.

Visiting Judge Robert Moore handed out the punishment in a Midland County court Tuesday afternoon after the sheriff was found guilty of six charges in the case: two third-degree felony counts of retaliation, two third-degree felony counts of misuse of official information, and two class A misdemeanor counts of official suppression.

Roberts faced up to 10 years in prison on the charges. Moore however sentenced the sheriff to four years in prison, which  were suspended for four years of probation; 100 days in Winkler County jail, which the sheriff will serve; a $1,000 fine for each charge ($6,000 total); a removal from office as sheriff; a waive of his right to an appeal; and a permanent surrender of his Texas Peace Officers License.

via mywesttexas.com

Click on the "VIA" Link for the full article.

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******************************************************

Sincerely,

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Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618

150,000 + Nurse-Reviewed & Approved Nursing Links

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Good Samaritan Laws & Acts. Do They Cover Nurses Volunteering Nursing Care When A Citizen Goes Anaphylactic.

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See also: Medical, Legal Nurse Consultants, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

To receive each case and supporting resources by E-mail weekly,
please click here. Subscriptions to the Case of the Week are Free.

Summary:  "Off-duty" healthcare professionals rendering
Emergency aid are in most cases "covered" by the Good
Samaritan Acts.  These are laws enacted in each state
that provide some degree of immunity from liability for
good faith efforts in giving emergency care.  In this
case, a nurse and physician were sued for providing
assistance in a volunteer function at a "first-aid" station.
Good Samaritan "immunity" was not recognized by the
courts.

A nurse, physician and several others volunteered to help
out with a first-aid station at a food festival being held locally.
 During the festivities one attendee would suffer an anaphylactic
attack.

The man had a known allergy to fish and helped himself to a
"gumbo" mix that contained the allergen.  He proceeded to experience
an anaphylactic allergic reaction.  The event "first aid squad" was
notified only of a "problem" and the person's location.

"Anaphylactic Shock

is the most severe form of allergy which is a medical emergency,
is a type I reaction in Gell And Coombs Classification .An often
severe and sometimes fatal systemic reaction in a susceptible
individual upon exposure to a specific antigen (as wasp venom
or penicillin) after previous sensitization that is characterized
especially by respiratory symptoms, fainting, itching, urticaria,
swelling of the throat or other mucous membranes and a sudden
decline in blood pressure."2

Of those present, all but a nurse remained at the station.  With the
physician and others on the way to assist the victim, clearly someone
had to stay at the station in case there were other emergencies.  The
question would arise of whether or not their actions were covered
under existing Good Samaritan Laws.  A key consideration is whether
or not a legal "duty to assist" the victim was created when the
responsibility to "volunteer" was accepted.

"Flynn v. United States, 681 F. Supp. 1500, 1506 (D. Utah 1988),
modified in part, 902 F.2d 1524 (10th Cir. 1990). Good Samaritan
laws responded to the common law rule that made one liable for
negligently rendering voluntary emergency assistance by extending
immunity from suit, thereby encouraging humanitarian acts by
licensed medical providers."3

Arriving on the scene, not knowing what to expect, they found
the person symptomatic, still conscious and standing on his own.
He indicated that he'd had a reaction and was in need of "a shot."

"Symptoms of anaphylactic shock include dizziness, loss of
consiousness, labored breathing, swelling of the tongue and
breathing tubes, blueness of the skin, low blood pressure, and
death bronchospasm"1

The physician recognizing the anaphylactic nature of the situation
requested one of the others obtain "epinephrine," while she stayed
with the patient.

When the other member of the squad returned with a single "Epi pen."
 The physician administered a dose.  The patient claimed to not have
obtained any relief.  A second shot was requested.  The pen was a
single dose unit only.  Having already used the available dose, the
physician explained it would be nearly empty.  There was no other
immediate source of epinephrine available at the time.  Unable to
offer an alternative, the physician gave the patient a second shot with
the same injector hoping it might still contain "some" medication.

Again the patient did not obtain relief.  With symptoms persisting,
the patient's condition deteriorated.  At this point an ambulance was
on the way, the nurse had been relieved at the station and came up
to assist, still unaware of what the problem had been.

When she came upon the patient, the best she could do was stay
with him until the emergency medical personnel arrived.  The
patient would complain of increasing shortness of breath.  En route
to the hospital, he would slip into a coma.  He would die the next day.

A lawsuit was filed naming both the physician and the nurse alleging
a "wrongful death."  Both the nurse and physician fought this in court.
 In the initial trial, the complaint was dismissed.

They argued for protection under the Good Samaritan Acts of the state.
  This legislation was enacted to encourage health professionals to
render aid at the roadside.  Previously, professionals had and still do
hesitate to assist for fear of being sued by the injured party.

"Because of the pervasive myth of liability in the medical professions,
most states have enacted some form of Good Samaritan law prohibiting
a patient from suing a physician or other health care professional for
injuries from a Good Samaritan act. To trigger the protection of such
an act, two conditions must be satisfied: it must be a volunteer act, and
the actions must be a good-faith effort to help. Displacing a neck fracture
in an effort to do rescue breathing might be malpractice in the Emergency
Room, but it is not bad faith on the roadside."4

While a Good Samaritan Act may protect you in state-specific circumstances
from being found and held liable, it will not protect you (nor will an
employer's malpractice insurance policy) from being sued in the first place.

In most states there is no obligation for a bystander to render aid or
legislation to penalize those that do not decide to get involved.
Minnesota, Vermont and Wisconsin are exceptions to this rule.
Minnesota statutes follow:

"A person at the scene of an emergency who knows that another person
is exposed to or has suffered grave physical harm shall, to the extent
that the person can do so without danger or peril to self or others, give
reasonable assistance to the exposed person. Reasonable assistance
may include obtaining or attempting to obtain aid from law enforcement
or medical personnel. A person who violates this subdivision is guilty
of a petty misdemeanor. "5

A common thread in each of the Good Samaritan laws is that no
immunity will be afforded for specific exceptions.

"The most commonly stated exception to immunity is for conduct that
is willful and wanton. Many jurisdictions also exclude other categories
of conduct, such as conduct that is grossly negligent, reckless, malicious,
in bad faith, fraudulent, or intentionally tortious or that is a knowing
violation of law. A few even included ordinary negligence, which arguably
negates the protection afforded."6

In the state of Rhode Island, in which this event occurred, there are
no specific laws requiring that a bystander give assistance.

Interestingly, immunity by the state laws is granted in the following
which do not specify volunteer medical and first aid activities.

"Rhode Island law also grants immunity from civil damages to:

(1) Persons rendering service as, or assisting, a manager, coach, instructor,
umpire, referee or official in certain interscholastic or intramural
sports programs;

(2) Any uncompensated person voluntarily serving as or assisting a
manager, coach, instructor, umpire, referee or official in a youth
sports program organized and conducted by or under the auspices
of a nonprofit corporation; or

(3) Directors, officers, trustees or employees of any nonprofit
organization, authorized to do business in the state, that organizes,
conducts or sponsors a youth sports program.208"6

It is debatable whether the initial trial led to a dismissal on grounds
of protection under existing Good Samaritan laws, or simply a lack
of evidence to prove negligence.  Of these, the latter is more likely.

With the complaint initially dismissed, the patient's estate appealed.

Questions to be answered.

1. In rendering care to the patient in a state of anaphylaxis, did
both the nurse and physician perform to the best of their abilities
with the resources available to them.

2. In rendering emergency aid to the patient, were they covered by
the state's existing "Good Samaritan" laws.

The plaintiff's attorneys would argue that negligence had been
a factor in the patient's death.  They accused the physician and
nurse of arriving on the scene "unprepared" to deal with the situation.

Interestingly, the plaintiff could offer no expert witness testimony
to support this.

In deciding the second question, the court explicitly stated that
"it assumed the defendants were not covered under Good Samaritan Laws."

This is alarming in that if the plaintiff had been able to produce
sufficient expert testimony to prove negligence, the nurse and
physician may well have been held liable.

In light of these circumstances,  the ruling of the lower court was
affirmed.

It sends a frightening message to nurses, medical and health care
personnel who chose to "volunteer" their expertise in times of need.
Some state laws do require action in specific circumstances:

It is unclear whether this opinion was offered because the assistance
was "organized."  Is an exception made to the Good Samaritan Acts
for First Aid Squads and Organized Emergency Medical Personnel
regardless of whether or not they charge the patient for their services?

Troubling questions for the individual when deciding whether or not
to render aid.  The answers and exceptions are defined in individual
state laws that vary widely.

Many nurses rely on malpractice insurance provided by their
employers to cover them at work.  It is highly unlikely that such
a policy would cover them while performing volunteer duties.

If you accept responsibility to perform expected duties either on
a paid or volunteer basis, for a profit or non-profit organization, you
may not be covered under otherwise applicable Good Samaritan Statutes.
If you chose to protect yourself by carrying malpractice insurance
policy, it would be wise to make sure this coverage is specifically included.

Related link Sections:

Direct Patient Care Links
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Good Samaritan Laws & Acts:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/good.samari...

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Sources:

1. 38 RRNL 4 (September 1997)

2. Health on The Net Foundation. July 2, 1998.  HON Allergy Glossary Anaphylactic Shock. Retrieved July 18, 1999 from the World Wide Web:  http://wolfgang.hcuge.ch/Library/Theme/Allergy/Glossary/shock.html

3. Utah State Courts. Filed November 14, 1997.  Hirpa v. IHC Hospitals, Inc., No. 960180.  Retrieved July 18, 1999 from the World Wide Web:  http://courtlink.utcourts.gov/opinions/supopin/hirpa.htm

4. Law and the Physician Homepage.  No Date Given.  Good Samaritan Laws. Retrieved July 18, 1999 from the World Wide Web:   http://plague.law.umkc.edu/Xfiles/x894.htm

5. LawGuide.  1998.  Minnesota Good Samaritan Law.  Retrieved July 18, 1999 from the World Wide Web:  http://www.lawstreet.com/lawguide/sigsgomn.HTML

6. Carter-Yamauchi, Charlotte A. 1996.  Volunteerism - A Risky Business? Retrieved July 18, 1999 from the World Wide Web:  http://www.hawaii.gov/lrb/vol/volchp3.html
 

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/071899.htm

Send comments and mail to Andrew Lopez, RN

Created on July 14, 1999

Last updated by Andrew Lopez, RN on Monday, February 28, 2011

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Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?

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See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

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Summary: Nursing homes are frequently a patient's destination for
rehabilitation following surgery.  Common conditions fitting
this bill include large bone fractures, hip replacements and stroke.
Following these acute episodes, the patients are too unstable to
go home and not "sick" enough to have their hospital stays
reimbursed by insurance companies.  The purpose of admission
to a nursing home is to help the patient regain lost function,
strength and health.  In this case, the patient would remain in the
Nursing Home till her death of complications.

The patient was admitted to a state owned nursing home
following repair of a femoral fracture.  Her treatment plan
emphasized Physical, Occupational therapy and Nursing care
to provide for rehabilitation.

She had successfully undergone surgery to repair a fractured
femur.  The length of stay projected was six weeks.  During
this time, the patient's condition would worsen rather than
improve.

This is not an isolated incident.  Media attention is continuously
focusing on conditions in nursing homes.

"A TIME investigation has found that senior citizens in nursing
homes are at far greater risk of death from neglect than their
loved ones imagine. Owing to the work of lawyers, investigators
and politicians who have begun examining the causes of
thousands of nursing-home deaths across the U.S., the grim
details are emerging of an extensive, blood-chilling and for-profit
pattern of neglect."2

The patient's skin was intact and she was continent on admission.
She would develop multiple pressure ulcers on her bony
prominences.  These are frequently the consequence of inadequate
turning and poor nutrition.  Monitoring of both of these factors
are direct responsibilities of nurses and nursing home personnel.
If either is inadequate, a duty is owed to the patient by the nurse
to inform the physician.  The physician, once made aware, is
then charged with taking additional measures as needed.

The patient would have a Foley catheter inserted supposedly
for urinary incontinence.  Documentation would later show
that need for catheterization had not been established.

The patient had been fully continent on admission.  Her
rehabilitation plan called for her to ambulate to the bathroom
when needed.  An assessment of her ability to go on her own
was nowhere to be found at the time of her Foley catheter
insertion.  Development of a urinary tract infection is a known
complication of catheter use.  The patient would develop a
UTI soon after.

"In the last year, complaints against nursing homes in Texas
are up over 60%. Medication errors, under-staffing, unsanitary
conditions, neglect, lack of care, substandard care and injuries
from dangerous products, are but a few of the dangers. The
administrators of these facilities contend that the level of care
is excellent in Texas nursing homes but, state investigators and
Texas juries have been sending a different message."3

On the initial trial, the court dismissed the claims.  They based
this on the fact that the nursing home personnel were "state"
employees and supposedly immune from liability.

The patient's family appealed.

Questions to be answered:

1. Could the nursing home personnel in a public facility be
held liable for negligence in the care of the patient?
Specifically, could they be sued for not maintaining the
standards of care required by the state?

2. Were the "incidents" leading up to the patient's deterioration
reasonably "foreseeable" by a prudent caregiver in a
similar situation?

On appeal, the plaintiff presented multiple pieces of evidence
documenting neglectful incidents.

This documentation included fractures during transfers (one
requiring re-hospitalization and extensive surgical repair),
the development of skin breakdown, the development of
infections of the respiratory, urinary and gastrointestinal tract.

Each of these events suggested that care for the patient could
be falling below accepted standards.  Each of these events
could be identified as necessitating further therapy and
increasing the patient's length of stay.

In reviewing the Tort Immunity Acts of Illinois, it was
determined that liability could be assessed for acts of
negligence or omission in the patient's care.

It was clear from physical, mental and health status changes
that the patient was deteriorating.  These changes, specifically
the multiple injuries during transfers, development of skin
breakdown and infection could be traced to negligence in the
omission of required care.  Any time the treatments prescribed
by the physician are not carried out, or if it is not documented
that they have been carried out, the possibility of omission and
negligence is raised.

It is highly unlikely that if the treatments and care prescribed
had been given that the gross deterioration would have occurred.
In this case, documentation of care was not present.  Documentation
of "likely results of neglect" was present.

This underscores the necessity of properly documenting the care
you give.   Many facilities are adopting "charting by exception"
policies.  These are dangerous in that they may not account for
basic care given.  In saving time and nursing costs for a facility,
not fully charting care given can raise the question of a nurse's
omission and negligence later in court.

If the temptation to chart care that is not given is present, keep
this in mind.

If time for giving proper treatments and care is not there,
falsifying records is patently illegal.  It is an offense that
could cost you your license if reported to the State Board.

In the case of a lawsuit, it is much cheaper for a facility to
scapegoat a nurse, than defend one.  If reporting you to the
State Nursing Board, or threatening to will give their attorney's
a bargaining chip to keep an employee "quiet," about existing
conditions they'll use it.

"Generally, the nursing-home industry likes to settle lawsuits
quietly and often hands over money only in exchange for
silence."2

A nurse must decide if saving facility money by spending
less time charting or on patient care is worth possible liability
or loss of licensure down the road.  It is highly unlikely that
a nursing home or hospital will defend a nurse named in a
lawsuit.  This chiefly will happen only when the facility's
assets are at stake.

If conditions in a nursing home are visibly substandard, a
nurse must ask if it is wise to continue working in the facility.
Ask yourself.  Is the administration receptive to suggestions
for improvement?  Do they raise concerns over overtime and
time involved to complete care and charting?

As media attention and lawsuits increase, more nurses will
find themselves involved in legal actions.  If it's determined
that poor conditions existed yet nothing was done about
them, the cost in liability could be high.

"Palo Alto attorney Von Packard has studied the death
certificates of all Californians who died in nursing homes
from 1986 through 1993. More than 7% of them succumbed,
at least in part, to utter neglect--lack of food or water,
untreated bedsores or other generally preventable ailments.
If the rest of America's 1.6 million nursing-home residents
are dying of questionable causes at the same rate as in
California, it means that every year about 35,000 Americans
are dying prematurely, or in unnecessary pain, or both."2

Many states have "elder abuse" legislation mandating abuse
be reported.  Whistle blower legislation is slow in coming.
Currently the employer's interests are put first rather than the
patient's or employees in most cases.  Protections for nurses
that do report abuse are questionable in their effectiveness.
The risk of employer retaliation is high.

The chances of a nursing home or hospital defending you
against the State Board of Nursing when your license is
at stake over an incident are almost none.  In fact, it is
common for complaints to be filed by the facility where
a nurse has worked.

Unless you have a personal malpractice insurance policy,
you will be forced to pay for this representation out of pocket.
For less than the cost of a typical day's pay (around $70-$90
per year), most personal policies will provide representation at
no additional cost to you.

Related link Sections:

Direct Patient Care Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Foley Catheterization:
http://www.nursefriendly.com/nursing/directpatientcare/foley.catheterization.htm

Informed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.co...

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Operating Room (Surgical) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm

Nursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htm

Wound Care:
http://www.nursefriendly.com/nursing/directory/business/woundcar.htm

Sources:

1. 39 RRNL 12 (May 1999)

2. Time Magazine.  October 27, 1997. Fatal Neglect. Retrieved July 11, 1999 from the World Wide Web: http://cgi.pathfinder.com/time/magazine/1997/dom/971027/nation.fatal_neglect....

3. Law Offices of James K. Burnett, P.C. 1999.  Nursing Home Negligence. Retrieved July 11, 1999 from the World Wide Web: http://www.nursinghomenegligence.com/
 

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm

Send comments and mail to Andrew Lopez, RN

Created on July 11, 1999

Last updated by Andrew Lopez, RN on Monday, February 28, 2011

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******************************************************

Sincerely,

Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618

150,000 + Nurse-Reviewed & Approved Nursing Links

http://www.4nursing.com
http://www.inspirationalnursing.com
http://www.legalnursingconsultant.com
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http://www.nursingcasestudy.com
http://www.nursingentrepreneurs.com
http://www.nursingexperts.com
http://www.nursinghumor.com

#Diabetic Coronary Artery Bypass #Patient, Septic & Noncompliant. #Nursing Duty and Responsibility Questioned.

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See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

For a free subscription to our publication:
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Summary:  Patient noncompliance can present serious challenges to
nurses  and physicians providing care.  If aware of the proper measures
to be taken, what happens when the patient does not agree
or comply with the course of treatment?  In this case, a patient after
having a coronary artery bypass grafting developed a sternal infection.
When advised by a nurse to return for treatment, the patient refused.

The patient was known to have Insulin-Dependent Diabetes Mellitus.
She would seek medical attention with a history of Angina (chest
pain).  Following the episode, she was referred for a diagnostic
cardiac catheterization.

"According to latest statistics from the American Heart Association,
roughly 323,000 cardiac catheterizations were performed in the
United States in 1994. The procedure provides doctors with
information about the heart's structure and its ability to function.
Doctors may also use catheterization to perform procedures on the
heart, such as balloon angioplasty.

To perform a cardiac catheterization, a thin catheter is inserted
through a small puncture wound in a blood vessel -- usually the
femoral artery in the leg. Using X-rays for guidance, doctors feed the
catheter through the circulatory system until it reaches the heart."2

Following the catheterization, an emergent multiple bypass surgery
was recommended by the Cardiologist.

"What is coronary artery bypass surgery?

A coronary artery bypass graft operation is a type of heart surgery. It
is sometimes referred to as CABG or "cabbage." The surgery is done
to reroute, or "bypass," blood around clogged arteries and improve the
supply of blood and oxygen to the heart. These arteries are often
clogged by the buildup over time of fat, cholesterol and other
substances.

The narrowing of these arteries is called atherosclerosis. It slows or
stops the flow of blood through the heart's blood vessels and can lead
to a heart attack."3

The patient would refuse and left the hospital Against Medical Advice
(AMA). Three days later the patient would return to the hospital and
provide an Informed Consent to the operation.  It was performed by
the Facility's Cardiac Surgery  Director assisted by a fourth year
resident.

""Revascularization with coronary artery bypass graft surgery
(CABG) and percutaneous transluminal coronary angioplasty (PTCA)
is well accepted as a method of relieving anginal pain and thus
improving quality of life. In addition, CABG has been shown to
improve survival in certain subgroups of patients with coronary
disease, which has led to the widespread use of this procedure in
revascularization. In 1991 407 000 bypasses and 303 000 PTCA
procedures were performed.1 Currently, coronary atherectomy,
various laser techniques, and coronary stents are being evaluated as
additional approaches to revascularization."4

Following the coronary artery bypass grafting, the patient would
remain in the hospital for ten days.

The patient would return for a follow-up visit just under two weeks
later with the surgeon.  Assisted by a cardiac nurse, the midsternal
incision was examined, staples were removed.  A portion was found
to be purulent, draining and healing poorly.

Cultures were obtained and sent, the patient would be scheduled for
another follow up visit a month later.

Four days later, the patient spiked a temperature.  She called the
medical center and spoke to the nurse who had assisted the surgeon.
After listening to the patient's complaints, the nurse instructed her to
return to the medical center for treatment.  She informed the patient
that her test results had come back and multiple infections had been
discovered from the midsternal wound in her chest.

"Approximately 2% to 20% of CABGs are complicated by a surgical-
site infection (SSI).4,5 Much of the literature on SSI following
cardiothoracic surgical procedures focus on deep chest infections,
which, although not frequent (complicating 0.5% to 5% of cardiac
procedures4,5), are important because of the high morbidity,
mortality, and immense costs they add to the healthcare system."5

The patient refused.  She stated that it was almost an hour's drive to go
to the medical facility.   In her "condition" she didn't feel she could
"make" the trip.

She asked the nurse if antibiotics could be "prescribed over the phone"
and started without her being evaluated.  The nurse informed her this
was not an option.

The nurse informed the patient that it would be best for her to return
to the facility where the operation had been performed.  If she
returned her condition could be evaluated and treatment initiated.  The
patient still refused.

Alternatively the nurse stated that the patient should seek immediate
medical assistance and contact her local physician.

The patient was unable to contact a local physician and did not go to
the Emergency Room immediately.  In fact, the patient was not
examined by her physician until almost ten days later.

At that time, ten days after the known Insulin Dependent Diabetic
patient had been informed by the nurse that she had a potentially life
threatening multiple organism infection in her chest, she was
readmitted to a local hospital.

"Surgical-site infection of the sternal wound includes superficial SSI,
deep sternal SSI, sternal osteomyelitis, mediastinitis, and endocarditis.
These often have been pooled together in the analysis of risk factors.
Host intrinsic risk factors that have been linked specifically to SSI of
the sternal wound include obesity,4,9-11 diabetes mellitus,4,9-13
current cigarette smoking,9 and steroid therapy,13 the former two risk
factors being the most frequently reported (Table 1). Kluytmans and
colleagues further demonstrated that the risk of developing SSI was
higher in the diabetic patient using insulin therapy than in the diabetic
patient treated with oral agents.12"5

A sternal infection was verified.  The patient would require
readmission and surgery to debride the wound and bring the infection
under control.  Part of her sternum would be removed in the process.

At the patient's request, the course of events was examined by the
Physician Medical Review Board.  She alleged that standards of care
had not been maintained.  She stated that negligence on the part of the
surgeon and the nurse had led to her infection and subsequent surgery.

The board dismissed the complaint.  They stated there was no clear
evidence of wrongdoing or negligence on the part of the nurse or
physician.

The patient filed a lawsuit regardless against the physician, facility
and the nurse accusing negligence.  The case was dismissed.

The patient appealed.

Questions to be answered:

1. Did the nurse fail to observe the applicable standards of care in her
conversation with the patient?

2. Was the nurse giving the patient "medical advice" when she
advised her to return for treatment?

3. Did the nurse mislead the patient or make any statements that could
have contributed to the patient's complications?

The physicians and the court when reviewing the nurse's performance
agreed it was appropriate.  The nurse was dealing with a known septic
patient with a history of noncompliance.  She instructed and
emphasized to the patient that an infection was present and required
treatment.

The nurse advised the patient of where the best treatment could be
obtained.  The patient was notified that if she could not return
immediately, that treatment should be sought elsewhere on an
emergent basis.

The nurse was giving medical advice.  In this case, the nurse was
telling the patient exactly what a competent surgeon would have told
her as well.

This is a special situation involving a nurse with advanced skills and
experience in a nursing specialty.  Nurses with specialized training are
recognized as competent to advise patients on pre-defined situations
according to their level of expertise.

A midsternal infection is a known complication of coronary artery
bypass grafting.  The nurse being aware of this was appropriate in her
counseling of the patient to seek immediate care.

The nurse in the eyes of the law would be and was held to the same
standards as a physician in the advice that was given.  The nurse did
in fact, maintain the standards of care expected in the situation.

Her responsibility or "duty" to the patient was to advise her of the
medical condition present (a septic infection), make recommendations
for treatment (return to the hospital), inform her of consequences of
not being treated and present alternatives.

This duty was fulfilled and recognized repeatedly by the medical
review panel and the courts.  It is unfortunate that the noncompliant
patient decided to pursue litigation regardless.

It demonstrates clearly how vulnerable even the most prudent nurses
are to being sued.  Often it is the case that nothing has been done
wrong, nor is there negligence likely.  It's a constitutional right for an
individual to initiate a lawsuit for real or perceived losses.

Makes an excellent case for carrying a malpractice insurance policy.
For the cost of a typical day's pay, you can have protection against
lawsuits without having to depend on an employer's policy being
adequate to protect you.

Related Link Sections:

Cardiac Arrhythmias Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/symptoms/cardiac.arrhy...

Cardiac Catheterization (Diagnostic) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/tests/cardiac.catheter...

Cardiac Links, Direct Patient Care on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/cardiac.htm

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Coronary Artery Bypass Grafting (CABG) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/cardiac/coronary.arter...

Direct Patient Care Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm

Informed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.co...

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Operating Room (Surgical) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm

Sources:

1. 40 RRNL 1 (June 1999).

2. WTVC NewsChannel 9.  1999.  Cardiac Catheterization: http://www.newschannel9.com/healthwatch/hw594.html

3. The American Heart Association.  1999.  Bypass Surgery, Coronary Artery:  Retrieved July 4, 1999 from the World Wide Web:  http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/bypass.html

4. American Heart Association.  1994.  Optimal Risk Factor Management in the Patient After Coronary Revascularization.  Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Scientific/statements/1994/129401.html

5. Infection Control & hospital Epidemiology.  April 1988.  Surgical-Site Infections After Coronary Artery Bypass Graft Surgery: Discriminating Site-Specific Risk Factors to Improve Prevention Efforts. Retrieved July 4, 1999 from the World Wide Web: http://www.slackinc.com/general/iche/stor0498/edit.htm
 

See also:Comparison Shopping

Children and Infants, Clothing and Fashion Accessories, Credit, Financial and Lending, Health & Beauty Aids, Travel, Hobby & Leisure,
Housewares, Home and Garden

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/070499.htm

Send comments and mail to Andrew Lopez, RN

Created on July 4, 1999

Last updated by Andrew Lopez, RN on Monday, February 28, 2011

via nursefriendly.com

--

******************************************************
For Health Information you can use, Follow, Connect, Like us on (Most Invites Accepted):
http://www.nursefriendly.com/social/

Twitter!
http://www.nursefriendly.com/twitter

Facebook:
http://www.nursefriendly.com/facebook

What's New:
http://www.nursefriendly.com/new/

Blogger:
http://4nursing.blogspot.com/

Linked In:
http://www.linkedin.com/in/nursefriendly

Nursing Entrepreneurs, Nurses In Business
http://nursingentrepreneurs.ning.com/

StumbleUpon,
http://www.nursefriendly.com/stumbleupon
******************************************************

Sincerely,

Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
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