Sunday, July 31, 2011

Why doctors can sometimes be their own worst enemies

“I don’t have the time … I don’t get reimbursed for that.”  This is an all too common refrain from primary care physicians and practice managers when ever the subject of improving physician-patient communications comes up.

I get it.   Primary care physicians in particular are under tremendous pressure to produce.   Just imagine, physicians in small primary care practices spend about 3.5 hours per week just on dealing with insurance-related paperwork.  Then there’s keeping up with recommended treatment guidelines, journals, and IT issues and routine staffing issues — not to mention routine patient care, much of which they in fact don not get paid for.  Physicians do have it rough right now.

But doctors can sometimes be their own worst enemies.

via kevinmd.com

--

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Saturday, July 30, 2011

Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?

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.

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


Summary: Nursing assessment skills are one of our most valuable
assets. They allow us to effectively evaluate our patients and
communicate significant findings to physicians and other members
of the healthcare team. In this case, a pregnant woman with a
previous history of miscarriage complained of vaginal bleeding
and abdominal discomfort. The assessment performed by the nurse
fell negligently short of the required standard of care.

The patient was a prison inmate on the evening in question. On arrest
and subsequent questioning, she clearly stated that she was pregnant.
The woman's medical history would reveal a previous miscarriage
had occurred.

"The medical term for a miscarriage is an abortion. Most miscarriages
start with vaginal bleeding which is initially slight and painless. This is
called a threatened abortion, because the pregnancy is threatened by the
bleeding. This bleeding is from the mother, and is not fetal blood. About
half the time this stops spontaneously and results in no harm to the
pregnancy. At this stage, the most useful test is an ultrasound scan (usually
done with a vaginal probe). If a fetal heartbeat can be seen, this means that
there is a 95 % chance that the pregnancy will proceed normally."2

While in custody, the patient would complain of vaginal bleeding and
abdominal discomfort. She claims that she made the nurse aware of this at
that time from her cell. She also claims to have made the nurse aware of her
previous miscarriage and that her current symptoms were similar.

According to the documentation of the event, the nurse responded by
taking her pulse and afterwards informing the pregnant patient that she
was "menstruating." The nurse did no further assessment nor did she
grant the patient's request for a "sanitary napkin." She instructed her to
"lay down" and then left.

"In such cases, the bleeding progresses, and the uterus starts contracting.
This is felt as painful cramps, and the mouth of the uterus (the cervix) opens.
This is called an inevitable abortion (because it cannot be stopped). If some of
the pregnancy has already been pushed out by the contractions, this is called
an incomplete abortion.

In patients with a blighted ovum, missed abortion, inevitable or incomplete
abortion, the treatment is a uterine curettage (D&C) - a short surgical
procedure which is performed to empty the uterus and remove the pregnant tissue."2

It seems incredible that given this presentation, the nurse would not have
taken a closer look. With the combination of physical symptoms and patient
history, it would be difficult to justify not taking further action. This was
exactly the situation the nurse faced when the issue went to trial.

You can consider at this point, what if the nurse was unfamiliar with the
symptoms and was unsure of what they represented? This is a familiar
scenario in nursing situations especially for the recent graduate or even
an agency, travelling or floating nurse.

It is a basic Nursing rule that if you are unsure, you ask another nurse,
a supervisor or call the physician. The nurse in this case did neither or
did not document doing so.

This applies when:

A patient is exhibiting symptoms which are clearly abnormal, but the nurse
does not know what they represent. Different symptoms can represent either
benign or emergent conditions in different patients. Only the physician can
make an informed decision to treat or not treat based on them. In making
this decision they rely on accurate and thorough assessments/history given
by the nurse. (Had a supervisor or physician been notified in this case, at the
very least, responsibility would have been shared among those notified or
liability shifted to the physician if no action was taken. In this case the claim
of negligence lied solely on the nurse's inactions).

It also applies when a nurse (or a patient) is unsure why a patient is receiving
a medication or are unsure if the dosage is correct. (Many mistakes are made
when physicians are writing orders or when they are transcribed, lives have
been saved or lost when nurses did or did not "catch" errors and called the
physician to clarify).

The patient's abdominal pain would worsen and she was unable to remain
laying down. She continued to complain to the nurse about her pain. The
nurse took no further action other than to inform the patient she would be
transferred to another cell for being noncompliant.

Early in the night the patient would have a miscarriage in her jail cell.

The patient would sue the nurse and the facility for failure to provide reasonable
and adequate medical care. The nurse would move to have the charges dismissed.

The court on review instructed that the issue go to trial.

Questions to be answered:

  1. Were the assessment and response rendered by the nurse adequate for the
complaints and symptomatology presented?

  1. Was a duty owed to the patient by the nurse to provide a higher standard
of care than was administered?

The court clearly recognized that a pregnant patient with active vaginal
bleeding and abdominal pain could have presented a medical emergency.
Follow-up assessment and further action on the part of the nurse was not
a matter of Nursing "judgement," it was mandatory.

It noted that the woman was in fact in the early stages of a miscarriage
and gave a classic symptomatology & presentation.

"Bleeding and cramping are the most common symptoms of miscarriage.
Pregnant women with these symptoms should consult their physicians
immediately. A physical examination, ultrasound testing and blood tests
gauging hormonal levels are used to ascertain whether the fetus has been
miscarried"3

The court observed that according to the documentation of the event,
the nurse assessed her condition and made decisions based on the
single taking of a pulse.

In assessing the abdominal pain of a actively bleeding pregnant patient,
standards of care as defined by the state Nurse Practice Acts would clearly
have dictated a more detailed assessment and physician notification.

The nurse whether inexperienced with the situation or indifferent towards
the patient's symptoms was clearly negligent. Prudent assessments
including a blood pressure, auscultation of bowel sounds & fetal heartbeat,
location/duration of abdominal pain, temperature, and respirations were
omitted from her evaluation. No physician (or applicable supervisory)
notification of the possible medical emergency was made.

There was no question that the "prudent nurse," that is an average nurse
in the same situation, would have taken more thorough steps to assess
the situation and evaluate the patient's condition.

By failing to take appropriate actions, the nurse allowed a potentially
life-threatening condition to go untreated.

It is worthy of note here that complaints against the nurse's license would
be expected (either by the plaintiff or the facility later). If the facility was
compelled to defend the nurse under an existing employer's malpractice
policy, it is likely that a subrogation action could be initiated afterwards.
If an award was made because of the nurse's negligence, the hospital could
try to recover that amount by suing the nurse as an individual. Filing a
complaint and having action taken against the nurse's license, in addition
to firing her would strengthen their position.

It is certain, that the employer would not defend the nurse against a
State Board of Nursing inquiry. A nurse with a separate personal malpractice
policy (An average cost today for a 1-3 Million Dollar Policy is near $80/year),
would have an attorney hired by the Nurse's insurance company and looking
out for his/her interests, not those of the employer. Specific malpractice
companies will also provide an attorney if a nurse is called before the
State Board of Nursing at no additional fee. This is a benefit you should
ask for when obtaining a personal malpractice insurance policy.

Related Cases:

July 25, 1999: Premature Child of Cocaine Addicted Mother Survives Abortion.
Physician Order: Leave To Die?
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?"
Hartsell v. Fort Sanders Reg. Med. Ctr. 905 S.W. 2d 944 - TN (1995).
http://www.nursefriendly.com/nursing/clinical.cases/072599.htm

May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints must be made with caution and good
judgement. Their intended purpose must be to protect either the patient or
others who may be injured by the patient including the staff caring for the client.
The ultimate determination of necessity is left with the physician. Often, the
moment to moment necessity is determined by the nurse. In this case a nurse
did not feel restraining the patient was necessary. When an injury occurred,
the patient sued.
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htm

Related Link Sections:

Clinical Charting and Documentation, Nurses Notes
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm

Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm

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

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

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

Miscarriages, Education & Support, Pregnancy Obstetrics & Gynecology
http://www.nursefriendly.com/nursing/directpatientcare/pregnancy.obstetrics.gynecology/miscarriages.htm

Nurse Practice Acts
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/nurse.practice.acts.htm

Neonatal Intensive Care Unit (NICU) Nurses
http://www.nursefriendly.com/nursing/directory/spec/nicu.htm

Obstetric Nurses
http://www.nursefriendly.com/nursing/directory/spec/obstetric.html

Premature Infants, Low Birth Weight Babies :
http://www.nursefriendly.com/nursing/directpatientcare/obstetrics/premature.infant.low.birth.weight.baby.htm

Sources:

  1. 40 RRNL 2 (July 1999)

  1. Malpani & Malpani & Cunha. 1998. Getting Pregnant: A Guide To the Infertile Couple. Retrieved August 8, 1999 from the World Wide Web: http://fertilethoughts.net/malpani/Chapter20.htm

  1. Medical College of Georgia. May 1996. Miscarriages. Retrieved August 8, 1999 from the World Wide Web: http://www.mcg.edu/News/96features/miscarriages.html

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm

Send comments and mail to Andrew Lopez, RN

Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care

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.

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


Summary: When a nurse accepts report and responsibility for the care
of a patient a duty to the patient is also accepted. This duty is to provide
a reasonable standard of care as defined by the Nurse Practice Act of the
individual state and the facility Policy & Procedures. In this case, a post-op
abdominal aneurysm repair patient was injured after falling from his bed to
the floor. When a lawsuit was filed the court initially mistook expert
testimony to imply the role of the nurse includes a guarantee of safety.

The patient was admitted for the surgical repair of abdominal aneurysm.
This is a weakening of the walls of the major artery supplying
blood from the heart to the abdomen and lower extremities. When this
occurs the vessel widens and there is a risk of rupture and rapid death from
internal hemorrhage. Once detected, physical examinations/assessments by
a Physician and Radiologic studies are performed to determine the extent of
the disease. Based on the findings, surgical repair may be indicated.

"What is an aneurysm and what causes it? An aneurysm is a balloon-like
swelling of the aorta. This is the main artery located in the middle of the
abdomen which transports blood down from the heart to the pelvis and to
the legs. Most commonly, the area of the aorta that is affected is the part
just below where the renal arteries going to the kidneys take off. The cause
of this balloon-like swelling is quite complex. Atherosclerosis certainly
co-exists with abdominal aortic aneurysms, but it is now thought to be
more of a predisposing factor rather than a single instigator of abdominal
aneurysms."2

In this case, the surgery was indicated and performed. The patient tolerated
the procedure well and was transferred to the Surgical Intensive Care Unit
(SICU)
. On the second day of recovery, the patient would fall from his bed.
A head injury was noted and the patient would die soon after. It was
alleged that he died as a direct result of the fall and resulting head injury.

"STATISTICS ABOUT FALLS

Every year in the United States, over $7 billion is spent on the treatment and
rehabilitation of people who are injured from falls.

Falls exceed automobile accidents as the number one cause of accidental death
for persons over 75.

National averages indicate that annually, acute care general care hospitals
experience approximately 1,000,000 fall occurrences, or about 1.5 per bed,
per year.

Thirty percent of hospital falls will result in injuries, including 5% serious
trauma such as hip fractures.

Thus, there are about 52,500 serious injury falls per year in U.S. hospitals.

Typically in acute care general hospitals, occupancy by high fall risk
patients exceeds 50% of daily census (i.e. patients are over 65 years of
age, are taking multiple medications and have one or more indications
for mobility restriction, such as muscle weakness, impaired vision, etc.)

hospitals typically incur $15,000 - $30,000 additional therapy cost per
serious inpatient fall resulting in trauma.

For example, for 100 beds, if there are 150 head per year and 5% are
serious and these cost an average of $22,500, the total cost burden is
$168,750. This equals $1687.50 of averaged cost for every bed in a
hospital."3

The estate of the patient sued the hospital claiming that applicable
standards of care concerning patient safety had not been observed.
The plaintiff produced expert Nursing testimony regarding the
applicable standards.

There is little argument that this 74-year-old, two day post-operative
male patient was indeed a high risk for a fall.

"Factors that contribute to head in older persons are physiological
(for example, decreased strength and vision), psychological (confusion),
social (maintaining independence), and environmental (absence of handrails
or inadequate lighting). Typically the factors that cause the fall are multiple
and interact with each other."4

Issues addressed were the frequency of patient observation, the presence of
side-rails in an post-operative patient, what medications was the patient under
the influence of at the time (would they warrant closer monitoring), and the
handling of the incident from when the patient was discovered to physician/
family notification and follow-up care.

In the testimony of the plaintiff's nursing expert, the statement was made
that it was the nurse's duty to "ensure" the patient safety. It was only a
single statement taken out of her testimony. None the less, the court focused
on this single point and decided on the basis of it to dismiss the charges.

The rationale given was that the plaintiff's argument was that the nurse was
responsible for "ensuring" the safety of the patient. This statement was
taken literally by the court.

With this clearly being an outrageous standard, the court granted summary
judgement for the defense. It added that in no law available on the books
was a healthcare provider defined as one who made guarantees or formally
"insured" a specific patient outcome. It paid little regard to the remainder
of the nursing expert's testimony in which the applicable standards of care
were outlined.

The plaintiff would appeal:

Questions to be answered:

1. Were reasonable precautions taken in the care of the deceased to
prevent a fall and otherwise provide for a safe environment.

2. Were the standards defined by expert nursing testimony adequate to
compose a credible argument against the hospital nursing staff in their
care of the deceased.

3. Was the initial court ruling in error when it based it decision on not
the general testimony but only specific portions.

When the appeals court reviewed the evidence presented, it decided that
there was in fact, sufficient evidence to justify a court trial on the issue.

It would state that the lower court was in error in that it made a decision
based on some rather than all of the testimony presented. It is unfortunate
but true that lawyers and judges like physicians and nurses sometimes
will narrowly focus in on specific facts, to the exclusion of others.

For the nurses involved in this case, it makes an excellent point that even
if a case is dismissed initially, it can be re-opened on appeal by either the
plaintiff or defense. Initial cases and appeals can take years to proceed.

Will a nurse have any idea of the facts and particulars of an event that
happened one to two, or even five years ago? Chances are practically
nonexistent that one will be able to recall details. It is for this reason that
daily charting must be complete and thorough. When a fall or an accident
or a mishap occurs, you must be particularly detailed in your documentation.

Your nurses notes form the medical and legal foundation of care that you
gave. When your performance is questioned or criticized in court or before
a state board of nursing, what is written in the chart is typically all you have
to stand on. It will typically be held in much higher regard than hearsay and
testimony based on "memory."

Related Cases:

May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htm

Related Link Sections:

Abdominal Aortic Aneurysm, Direct (Bedside Nursing) Patient Care Links
http://www.nursefriendly.com/nursing/directpatientcare/vascular/abdominal.aortic.aneurysm.htm

Clinical Charting and Documentation, Nurses Notes
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm

Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm

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

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

Falls, Injuries & Prevention, Direct (Bedside Nursing) Patient Care Links
http://www.nursefriendly.com/nursing/directpatientcare/falls.injuries.prevention.htm

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

Informed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.consent.medical.legal.htm

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

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

Nurse Practice Acts
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/nurse.practice.acts.htm

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

Surgical Intensive Care Unit (SICU) Nursing Departments & Specialities
http://www.nursefriendly.com/nursing/directory/spec/surgical.intensive.care.unit.sicu.htm

Sources:

1. 36 RRNL 8 (January 1996)

2. A. S. Coulson, MD. No date given. An Inside Look At Aortic Aneurysms. Retrieved August 1, 1999 from the World Wide Web: http://www.inreach.com/dameron_heart/inside.htm

3. RN+ Systems. No date given. Factors Hospitals Should Consider For Effective Fall Prevention. Retrieved from the World Wide Web July 31, 1999: http://www.rnplus.com/tips.prob.opport.html

4. Haertlein, Carol. No date given. Falls In the Elderly Population. Wisconsin Geriatric Education Center. Retrieved July 31, 1999 from the World Wide Web: http://www.mu.edu/wgec/news/982/falls.htm

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/072599.htm

Send comments and mail to Andrew Lopez, RN

Monday, July 25, 2011

Premature Child of Cocaine Addicted Mother Survives Abortion.

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.

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


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.addiction/cocaine.htm

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.infant.low.birth.weight.baby.htm

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

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

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:

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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

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/072599.htm

Send comments and mail to Andrew Lopez, RN

Click on the "VIA" link to read the full article.

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Sincerely,

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

Sunday, July 24, 2011

Able To Play? Operating Room Jokes, Medical Humor

To subscribe, send a blank email to: nursingjokes-subscribe@topica.com

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A doctor has come to see one of his patients in a hospital.

The patient has had major surgery to both of his hands.

"Doctor," says the man excitedly and dramatically holds up his heavily bandaged hands.

"Will I be able to play the piano when these bandages come off?"

"I don't see why not," replies the doctor.

"That's funny," says the man. "I wasn't able to play it before."

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Five Minutes

A hospital posted a notice in the nurse's lounge saying: "Remember, the first five minutes of a human being's life are the most dangerous." Underneath, a nurse had written: "The last five are pretty risky, too."

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Peek-A-Boo

The famous female Olympic skier, Picabo Street (pronounced Peek-A-Boo), is not just an outstanding athlete, she is also a nurse. She currently works at the Intensive Care Unit of a large metropolitan hospital.

She is not permitted to answer the telephone, however, as it caused simply too much confusion when she would answer the phone and say, "Picabo, ICU."

(Please note, this is in fact an urban legend as verified by "snopes.com" we'll keep it here for clarification anyhow.)

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Interns think of God, residents pray to God, doctors talk to God, nurses ARE God.

The nurse who can smile when things go wrong is probably going off duty.

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A Routine Physical, Nursing Jokes, Medical Humor:"A man goes to a doctor for a routine physical. The nurse starts with the basics. "How much do you weigh?" she asks."
http://www.nursinghumor.com/physical

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A Small Prick, Bedside Nursing Jokes, Patient Humor:"About a week ago I broke my ankle (in three places) and was in the hospital for several days. My first night in the hospital, after having surgery to rejoin my bones with pins and plates and such, I was in a great deal of pain and quite immobile."
http://www.nursinghumor.com/prick

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How Nurses Do It, Nursing Jokes, Occupation Humor:
http://www.nursinghumor.com/

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Top Ten Reasons I Went Into Nursing, Nurse Jokes, Healthcare Humor:"10. I love to wear white support hose. 9. I get a kick out of arrogant doctors."
http://www.nursinghumor.com/went

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Able To Play? Operating Room Jokes, Medical Humor:"A doctor has come to see one of his patients in a hospital. The patient has had major surgery to both of his hands."
http://www.nursinghumor.com/play

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Charge Nurse & The Genie Who Granted Three Wishes:
http://www.nursinghumor.com/charge/

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Getting Even, Nursing Jokes, Physician Humor:
http://www.nursinghumor.com/getting/

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HMO Blues, Nursing Jokes, Managed Care (HMO) Humor:
http://www.nursinghumor.com/blues

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Medical Office Bartering, Nursing Cartoons, Medical Comics, Doctor Jokes:
http://www.nursinghumor.com/bartering/
Categories: Bedside Nursing Jokes, Patient Humor, http://www.nursinghumor.com/bedside/
Doctor Jokes, Medical, Patient, Hospital Humor, http://www.nursinghumor.com/medical/
HMO Jokes, Health Maintenance Organization Humor, http://www.nursinghumor.com/hmo/
Nursing Cartoons, Medical Comics, Healthcare , http://www.nursinghumor.com/cartoons/
On The Job Jokes, Employment Humor, http://www.nursinghumor.com/employment/

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New Password, Bedside Nursing Jokes, Computer Humor:"A female nurse manager was helping a smug male resident access his computer account on the hospital information system."
http://www.nursinghumor.com/password

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Patient Reassurance, Bedside Nursing Jokes, Patient Humor:
http://www.nursinghumor.com/reassurance

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Practical Jokes, Bedside Nursing Humor, Doctor Jokes
http://www.4nursing.com/humor-nursing-humor-practical-jokes.html

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Respiratory Assessments, Bedside Nursing Jokes, Patient Humor
http://www.4nursing.com/humor-bedside-nursing-jokes-respiratory-assessments.html

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Get Well Quick, Bedside Nursing Jokes, Law Enforcement Humor:
http://www.4nursing.com/humor-bedside-nursing-jokes-get-well-quick.html

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Top Ten Most Commonly Used Nursing Phrases:"10. "No, really, I don't mind changing the TV channel for you . . . again."

9. "I'm sorry, it's not THAT kind of Tylenol."
http://www.nursinghumor.com/phrases

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Top Ten Reasons I Went Into Nursing, Top Ten Jokes, Bedside Nursing Humor
http://www.nursinghumor.com/into

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Top Ten Reasons To Work An Overtime Shift On The Weekend, Nursing Jokes, Top Ten Humor:
http://www.nursinghumor.com/weekend

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Black Testicles, Bedside Nursing Jokes, Patient Care Humor:
http://www.nursefriendly.com/nursing/humor/bedside.nursing.humor.black.testicles.htm

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The Center of Attention, Medical Jokes, Patient Humor:
http://www.nursefriendly.com/nursing/humor/medical.doctor.physician.patient.jokes.the.center.of.attention.htm

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Top Ten Worst Hospital Visitors, Bedside Nursing Jokes, Top Ten Humor:
http://www.nursinghumor.com/worst

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Patient Guidelines And Responsibilities, Bedside Nursing Jokes, Patient Humor:
http://www.nursinghumor.com/

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Ambulances As Medical Necessities, Medical Jokes, Patient Humor:"These are all GENUINE replies from patients asked why they needed an ambulance to and from hospital..."
http://www.nursinghumor.com/ambulances

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The Foley Insertion, Foley Catheter Jokes, Bedside Nursing Humor
http://www.nursinghumor.com/insertion

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Nurse Hell, Bedside Nursing Jokes, Nurse Humor
http://www.nursinghumor.com/hell

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How Many Nurses Does It Take To Change A Lightbulb? Bedside Nursing Jokes, Medical Humor
http://www.nursefriendly.com/nursing/humor/bedside.nursing.humor/how.many.nurses.does.it.take.to.change.a.light.bulb.htm

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Multiple Specimens, Medical Jokes, Doctor & Patient Humor
http://www.nursefriendly.com/nursing/humor/medical.doctor.physician.patient.jokes.multiple.specimens.htm

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The Ranks of a Hospital, Nursing Jokes, Bedside Nursing Humor
http://www.nursefriendly.com/nursing/humor/bedside.nursing.humor/the.ranks.of.the.hospital.htm

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Most Commonly Used Phrases By Nurses, Bedside Nursing Humor, Nurse Jokes
http://www.nursinghumor.com/most.commonly.used.phrases.by.nurses.htm

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Caffeine Is My Shepherd, Bedside Nursing Humor, Employment Jokes
http://www.nursinghumor.com/caffeine

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Top Ten Reasons To Date A Nurse! Nursing Jokes, Top Ten Humor:"White scrubs are see through. We asses all areas of the body. Scrubs make for easy access."
http://www.nursinghumor.com/date

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