March 2004 Newsletter-Mine by dandanhuanghuang


									               THE LNC NEWSLETTER
                                                        PRESENTED BY:
                                          Medical-Legal Interface
                                                    Patient Safety: Restraint Standards
  March 2004                                              Maggie Driscoll RN,BSN,CCRN,CLNC
 Volume 3, Issue 6           Restraints as Deterrents to Falls and Injury            local levels.
                                      The use of physical and chemical restraints              All hospitals and healthcare facilities
                            has long been accepted as standard practice when         receiving Medicare and Medicaid reimbursement
 Inside this issue:         aimed at preventing falls and injuries in hospitalized   must comply with specific standards outlined by
                            patients and long-term care residents. However,          the Health Care Financing Administration (HCFA,
                            recent studies have demonstrated that restraints do      now known as Centers for Medicare and Medicaid
 Case Managers              not necessarily prevent injuries. In fact, physical      Services) and The Joint Commission of
    as LNCs           3     restraint use has been associated with such adverse      Accreditation of Healthcare Organizations
 Not Everything             outcomes as pressure sores, strangulation deaths,        (JCAHO). Restraint care may also be guided by
  Green is Irish      4     decreased mobility, increased agitation and              state code such as in North Carolina
 in March, OR:              depression. Often there is no increase in serious        Administrative Code, Section 3302R: “The patient
 Mold, Friend or            injury when physical restraints are replaced with        has the right to medical and nursing treatment that
      Foe?                  other less restrictive safety measures based on the      avoids unnecessary physical and mental
  The Unasked         5     individual's specific needs. A restrained patient who    discomfort”.
    Question                falls is more likely to sustain a more serious injury              The Joint Commission of Accreditation of
                            than one who falls while unrestrained.                   Healthcare Organizations defines physical
                                             Restraint Standards                     restraints as “any manual method of physically
                                      Rising concerns over injury, death, loss of    restricting the patient’s movement, or normal
                            dignity and independence among restrained patients       access to his/her body, material, or other
                            in both long-term and acute care facilities prompted     equipment, attached or adjacent to the patient’s
                            regulatory agencies to define the standards of care.     body that (s)he cannot easily remove.”
                            Restraint standards span across national, state and                                           Cont on p. 2

 What you always Wanted to Know about Medicare Set Asides but Were Afraid
                                 to Ask
                               Pattie Patterson RN, LNCC, Life Care Planner, MSA Allocator
          Medicare Set Aside (MSA) actually affects not only          compliant with its terms, there is no danger of CMS refusing to pay
worker’s comp injuries but motor vehicle accidents and personal       if, for some unforeseen circumstance, the funds are exhausted before
injuries, i.e. injuries involving liability insurance, no-fault       the end of the beneficiary’s life.
insurance and uninsured motorist insurance, but in this article I                     Criteria for Submitting a Claim to CMS
will be speaking only to the worker’s comp injuries, just to not                  There are two classifications for submitting to CMS
confuse the article, although the others have the same criteria for   • Class I - The individual is a Medicare beneficiary at the time of
submission to CMS (Center for Medicare and Medicaid                       the settlement regardless of the amount of the settlement.
Services).                                                            • Class II – The individual is not currently a Medicare beneficiary
          In 1980 the Medicare Secondary Payer (MSP) statute              at the time of the settlement but:
was created as part of the Omnibus Reconciliation Act (OBRA)              o The total amount of the settlement is over $250,000.00
to ensure that Medicare was only secondarily responsible for                  (including attorney fees and costs) and
payment of medical expenses for persons covered by Medicare               o There is a reasonable expectation of Medicare enrollment
who were also covered by another type of private insurance.                   within 30 months of the settlement date. This can be a
This means if a worker is injured in a work related accident and              reasonable expectation if the individual:
this same worker meets certain criteria, then the settlement must                Is 62 ½ years of age.
be approved by CMS in order to assure that CMS’s interests are                   Has applied for SSD (Social Security Disability) benefits.
being served.                                                                    The individual was denied SSD benefits but anticipates
                      What Exactly is a MSA?                                     appealing.
          MSA is a designated amount of the entire settlement                    Is in the process of appealing or refilling.
that is set aside to pay for medical services and/or supplies that               Has end stage renal disease and is not yet on Medicare.
would normally be paid by Medicare were it not for the                            For any client who falls within these criteria, a claim must
insurance involvement. These allocated funds are to be used to        be filed to CMS for approval before you settle the case, or it could
pay only the items that would normally be paid by Medicare. As        back and bite you and/or your client later on down the line.
long as Medicare approves the amount and the beneficiary is                                                                        Cont on p. 3
Volume 3, Issue 6                                                                                                                             Page 2

                                            Patient Safety: Restraint Standards
   Continued from page 1

     Under JCAHO guidelines, healthcare                 aggressive and the least restrictive method    to physical and chemical restraints.
     facilities are required to determine their         to assure patient safety and/or the safety     Alternatives may include the
     own systematic approach for restraint use.         of others is a restraint. A registered nurse   following interventions:
     Because restraints are considered a form           may initiate the restraint, but a physician    environmental modification, limiting
     of medical treatment, they can only be             must make a face-to-face assessment            physical accessibility to lines and
     used under the direction of a physician. In        within one-hour of the initiation of the       tubes, pain relief, reality orientation,
     ordering the use of restraints, the                restraint. Chemical restraints are also        anticipation of toileting and hydration
     physician must specify the medical reason          considered restraints for the purposes of      needs, distraction, and physiological
     for using the device (i.e., confusion,             behavioral management. A drug is used          assessment of factors contributing to
     prevention of removal of tubes and lines),         as a restraint when it is used to control      confusion.
     the type restraint (i.e., wrist mittens, vest,     violent or aggressive behavior or to                     When reviewing medical
     side rails) and the length of time over            restrict the patient’s freedom of              records of a restraint-injured client, it
     which it can be used. Restraint use must           movement and is not considered standard        is imperative to analyze both the
     be carefully monitored and documented,             treatment for the patient’s medical or         medical and nursing processes that
     and its effectiveness must be continuously         psychiatric condition. Restraint               lead to the use of the restraint.
     evaluated. An effort must always be made           assessment and monitoring frequencies          Physiologic imbalances that lead to
     to use the least restrictive available             are also determined by patient age. The        confusion, such as hypoxia (low
     method of restraint, and to restore each           younger the patient, the more frequent the     oxygen levels), electrolyte
     individual to his or her maximum possible          assessment should be.                          abnormalities and uremia require
     level of independence.                                        Side Rails as Restraints            prompt medical treatment.
                In acute care facilities, restraints               In 1995 the Food and Drug           Medication regimens that may lead to
     are either for acute medical-surgical care         Administration (FDA) issued a safety           confusion or toxicity should be
     or for behavioral management. Each                 alert, citing concerns of entrapment,          carefully examined upon admission.
     category has its own specific restraint care       injury and strangulation death resulting       Medications that are usually
     guidelines for physician prescription,             from the use of side rails. Between 1985       therapeutic for the elderly patient can
     restraint selection, assessment, and               and 1999, the FDA received 371 reports         quickly become toxic in the face of an
     ongoing monitoring. An example of                  of patients caught trapped, entangled or       acute illness. The need for restraints
     restraints used for acute medical-surgical         strangled in hospital beds. Of these           should be assessed according to
     care may be immobilizing the hip and arm           mostly frail, elderly or confused patients,    institutional and regulatory
     to prevent a confused patient from getting         228 died as a result.                          requirements. Restraint
     out of bed unassisted and removing an IV                      To date, no research study has      documentation should include: the
     line after a hip replacement. A registered         demonstrated that the use of side rails        patient’s behavior requiring restraint
     nurse may initiate a physical restraint            prevents injury as a result of a fall. In      intervention, immediate physician
     based on professional nursing judgment.            fact, a patient who falls from a greater       notification if this is a change in
     A verbal or written order from the                 height while climbing over a side rail is      patient condition, the appropriate
     physician must be obtained within 12               more likely to be seriously injured than       physician order, response to restraint
     hours of the initiation of the restraints.         one who falls from the bed mattress.           alternatives, the appropriate nursing
     According to JCAHO standards the                              HCFA (CMS) defines restraints       observation, assessment and
     physician must be notified immediately if          to include side rails as well: any device      intervention of the restrained patient,
     the initiation of the restraint is a result of a   that restricts a patient’s voluntary           the type of restraint, time of
     change in patient condition. Patients in           movement or access to his body and that        application and patient response to the
     restraints must be monitored at least every        can’t easily be removed by the patient.        restraint. Negative outcomes
     2 hours. If the ongoing patient assessment         Most healthcare facilities now use beds        (pressure ulcers, contractures and loss
     indicates a clinically justifiable need for        that have 4 side rails. A half or quarter-     of ability to ambulate) associated with
     continued restraint use in acute medical-          length upper side rail is not considered a     restraint use should also be carefully
     surgical care patients, then the order for         restraint if the patient uses it to assist     assessed.
     restraints must be renewed each calendar           himself into or out of bed. Additionally, 4              Litigation surrounding falls
     day. While JCAHO has set minimum                   half-length side rails are not considered a    and restraint-injury claims continues
     standards for restraint care, hospital policy      restraint if the patient requests them and     to rise. Just as the key to ensuring
     may actually mandate a higher frequency            the patient can lower them before entering     patient safety is to formulate the plan
     of assessment and monitoring of                    or exiting the bed.                            of care based on the patient’s
     restrained patients.                                        Alternatives to Restraints            individualized needs, careful analysis
                The behavioral restraint                           In an effort to use the least       of the medical facts will assist
     management standard applies in                     restrictive method of restraint available to   attorneys in determining the merits of
     emergency situations where the patient’s           ensure patient safety and dignity,             each individual case.
     behavior has become violent or                     healthcare researchers have studied and
                                                        recommended varying alternatives to
Medical-Legal Interface                                                                                                                   Page 3

                                                    Case Managers as LNC’s
                                                           Robert Morrison, RN BSN
             The case that has occupied much       accident. However, the results were             will form the basis of the attorney’s
   of my time the past week illustrates the        declared invalid even by the evaluator. It      courtroom presentation. What the LNC
   need for plaintiff attorneys to keep nurse      was too early in the course of treatment to     does best is provide a legally astute
   case managers close at hand. This case          do this. He was still regaining his abilities   assistant with a medical background. When
   started for us almost two years ago and         at this point. Even if they had been able to    you’re deciding what nursing backgrounds
   has been very complicated throughout.           measure exact limits, they would have           to have available, don’t forget the case
   We are preparing for court this spring and      changed as soon as John progressed to the       manager. Their occupational brief is to
   hoping to bring the patient closure at last.    next stage of therapy.                          bring order to chaos and keep all of the
             John (not his real name) is a 48                 To make sure all of the              different pieces together in a single,
   year-old man who was involved in an             individual providers and managers had, in       sensible picture.
   automobile accident in 1998 injuring            fact, brought John to his maximum state
   himself and his wife. The other driver was      of recovery an Independent Medical                   Medicare Set Asides
   found at fault and ticketed. However, her       Evaluation (IME) was done. This looked           Continued from page 1
   insurance coverage had not anticipated          at all of the information starting with the
   multiple injuries. The medical treatment        accident through the current date. Detailed               How the Process Works
   was handled through two different               medical records were provided to the IME                  The MSA Allocator, a person
   insurers during the next four years. Each       physician which showed all of the activity      trained in drafting and submitting MSAs to
   insurer provided its own nurse case             from the various providers. After               CMS, will collect all pertinent medical
   manager, each steering the injured              reviewing all of the information at-hand,       information, and establish, from the life
   patients through a combination of family        this physician agreed that further              care plan how much of the monies need to
   practice, neurosurgery, therapy and rehab.      treatment was unlikely to improve John’s        be allocated to the MSA. Then the
   His wife’s case eventually reached              situation, and that he did appear to have       Allocater will, with the beneficiary, decide
   maximum medical improvement (MMI)               reached a state of maximum                      how the funds will be held in trust and who
   and was settled by the insurer. John,           improvement. He also provided a                 will administer the funds. This can be done
   however, was seemingly stuck in the             calculated impairment rating to help            by structured settlement annuity, placed in
   middle.                                         quantify John’s losses as a result of this      the bank with an executor or both. The
             Our first order of business was to    accident.                                       Allocator then prepares all of the necessary
   clearly establish John’s current medical                   Since John had not been able to      documents for the proposed settlement and
   status and needs. This was important, as        return to his previous occupation as a          submits these same said documents to CMS
   you cannot establish permanent                  truck driver it needed to be established        for approval. Once CMS approves the
   functionality (and thus damages) while          what his occupational situation was. A          settlement it will then need to be finalized.
   the patient remains in active treatment.        Loss of Earning Capacity evaluation was         Any negotiations related to the claim must
   The goal of treatment is to change and          done at this point by a certified vocational    be done prior to the submission of the final
   improve the patient’s ability and function.     counselor. This evaluation involved a           proposal, as once CMS approves it, it must
   You need to make sure that the medical          detailed work and educational history           stand as is.
   providers have done all they can to             from John covering his entire life. This            Why Should you Submit a MSA to
   advance the patient’s condition before you      allowed the counselor to establish what                             CMS?
   stop. By working directly with all of the       occupations John would be qualified for.                  The statue allows CMS to expect
   doctors involved we were finally able to        Then, by eliminating those whose                reimbursement for any and all conditional
   document a state of MMI in December of          physical requirements were beyond the           payments, payments they make while
   2002. An experienced case management            limits set in the FCE, the counselor was        awaiting the settlement. Also, if Medicare
   approach was used to bring all three            able to show what possibilities were left.      has to pay any future medicals on anyone
   doctors and the patient together to a single    The earning potential of these occupations      who has received a settlement because
   understanding.                                  was compared to that of his prior field of      Medicare’s interest was not protected by
             Next came the need to quantify        driving a truck. The difference between         submitting a MSA allocation for approval
   the patient’s damages. You always prefer        these figures represented part of the           double damage plus interest may be
   that they return to their pre-accident state.   damages suffered by John as a result of         assessed against all parties responsible.
   In this case it wasn’t possible, though he      the accident.                                             So, the next time you have a case
   did come further than he anticipated in the                Now, John’s attorney had all of      where the client meets the criteria for a
   beginning. An FCE (Functional Capacity          the medical information about his               possible MSA, do yourself and your client
   Evaluation) was performed to establish          damages. During this time the attorney          a favor and have a MSA Allocator glean
   his exact level of ability and function. A      had been gathering all of John’s financial      over the records to assure you that you’re
   long and intense two-day evaluation, its        records and pension information. When           meeting the burden of protecting
   basic purpose is to state clearly what the      this had been calculated as a single,           Medicare’s interest. You’ll be glad you
   patient can and cannot do, and where their      supportable figure it was added to the          did. For more information of other aspects
   limits are. One of the insurance case           medical damages to make a single                of MSA, please don’t hesitate to contact
   managers had this done a year post-             settlement package. It is this package that     me.
Volume 3, Issue 6                                                                                                                                      Page 4

               Not Everything Green is Irish in March, OR: Mold, Friend or Foe?
                                                         Sarah McLain RN, CLNC, CLCP
              Molds are common life forms.                Almost everyone suffers from some               microscopic spores (seeds), which enter the air and
   They can be found in areas where everything       kind of mold related problem. Many times,            cause various kinds of problems. If you breathe
   freezes as well as in the tropics where           however, the effects are mistaken for something      them in, they can cause problems inside your nose.
   everything is burning hot. They are found in      else, such as a headache. Is it a stress headache    The chemicals can irritate soft mucous membranes
   homes and schools and office buildings. They      or did walking into a moldy home give you the        inside the nose leading to sneezing and runny nose.
   are destructive to many different materials.      headache?                                            If you believe you have a cold, you can treat it
   They can eat away the leather in your shoes.                 Many people are taken off mood            incorrectly. What works on a cold or a bacterial
   They can eat away wood and wood products.         altering drugs after their homes are cleared of      infection, won't do a thing to mold infections. If
   They can invade your body and cause               mold. Some have actually avoided time in mental      mold spores enter your nose, you can also start
   diseases, including allergic reactions,           institutions by cleaning up their environments.      having allergic reactions. Again you get the
   dizziness, sleeplessness and irritability.        There was one case where the wife was three          sneezing, runny nose and parts of your body begin
              To sustain itself, mold releases       days away from being committed in a mental           to turn red and swell up. Sinusitis and infections
   chemicals into the surrounding moisture,          institution for severe depression. Her house was     can occur when these materials work their way into
   which break down the food source into             cleaned and the mold was removed and her             your sinuses. Millions of dollars are spent each
   smaller particles. The food particles mix with    depression vanished. There are plenty of             year on over the counter medications to incorrectly
   the water/juice mixture so the mold can suck      scientific studies which document the mood           treat sinus problems that are caused by mold. If
   it up. One example of how all these things        swings in people exposed to chronic mold.            mold products get into your lungs, they can lead to
   come together for the mold creature is in a                  Even in two paycheck families,            pneumonitis. The tender linings of the lungs have a
   forest. Mold grown on dead trees lying in the     children suffer more because they spend so much      hard time fighting off mold. The insides of the
   dark, damp forest. The tree used the sun to       time in daycare and schools. Because neither of      lungs are warm, moist and have a rich supply of
   create food and then stored that food. When       these places tend to be well ventilated, both are    easy to digest material. All the things mold needs
   the mold grows on the dead tree it uses the       notoriously high in mold contamination. Add this     to set up housekeeping.
   natural moisture of the forest. It burrows into   to the molds that children bring into the common                 Mold can cause dermatitis. Some
   the tree and secretes its juices. These juices    area from their homes and you can have a killer      soldiers who fought in the South Pacific area in
   eat away the stored food in the tree. Then the    combination. Most schools and daycares have          World War II have mold-induced dermatitis to this
   mold absorbs this food for its own use. The       carpets. The food and glue that kids drop on the     every day. Ringworm is another skin problem.
   mold is actually doing us a favor. If it didn't   carpet feed mold growth. In Sweden, school           Ringworm can be very destructive if occurring in
   eat away the dead creatures around us (trees,     officials are removing carpets from schools          places like hair regions. It will actually cut a ring
   leaves and bugs), we would be drowned in          because of the health problems they cause.           of hair away leaving something that looks like a
   debris. Mold is nature's little garbage                      The air handlers in many schools are      ring shaped scar. Otitis is a common problem
   disposal.                                         never turned on. Air filters are seldom changed.     among children. Molds such as Penicillium can
              Mold causes billions of dollars        So mold spores (seeds) float around looking for      wreak havoc with a child's ear. This is both a
   worth of damage to our food supply each           children's lungs and noses. Adding to the mold       costly and painful problem. Gastrointestinal
   year. How many times have you opened your         problem in schools is the toxic chemical problem.    distress is a common problem when mold is
   refrigerator and found green spots on your        When carpets are cleaned in schools, outbreaks of    swallowed. Why would we swallow mold? Simple,
   cheese? Did you throw that cheese away? Or        respiratory disease occurs among school children.    it gets in our food in the kitchen. Have you ever
   did you cut away the green part and eat what      The same thing happens in homes. Many carpet         found green spots on your cheese? Some people
   was left? Did you get sick? If not, luck may      cleaners contain formaldehyde, which damages         cut this bad part of the cheese off and eat what is
   have been with you. The large immigration         tender lungs.                                        left. While this keeps the antacid companies happy,
   of Irish potato farmers in the last century was              Almost daily someone is doing a story     this type of problem costs Americans millions of
   caused by mold attacking the potatoes in          in the news about a contaminated school and          dollars each year.
   Ireland. The Irish people were devastated         disease epidemics. The classic study on the mold                 Bone infections result if mold gets into
   when their main food source disappeared.          subject is the one in Morbidity & Mortality          the blood and travels to the bone. Usually this
   Starvation was everywhere.                        Weekly Report Jan 17, 1997. This case even           occurs when someone has a depressed immune
   The place mold has in history is not limited      appeared on TV. Nine kids in Cleveland, Ohio         system. But remember, mold can cause a depressed
   to just the Irish potato famine. Mold is          died from a mold (Stachybotrys chartarum),           immune system. Mold can cause endocarditis, an
   possibly the cause of the mummy's curse in        which was growing in their homes following           infection in the heart, through a surface wound. For
   Egypt (the people who went into the tombs         water problems (leaky pipes, water heaters, etc.)    example, after getting a tooth pulled, anything
   got sick and died mysteriously). The              The children died from lung damage caused by         growing in the fluids of the mouth goes through
   symptoms of the people who suffered from          mold spores destroying the tender lining of their    the hole in the jaw into the blood stream. Toenail
   the "curse" were similar to those caused by       lungs.                                               medications are selling in the millions of dollars
   Aspergillus mold. And this mold has been                     Many childhood illnesses from             each year. Toenail fungus causes thick, ugly
   found in the Egyptian tombs. It seems that        Attention Deficit Disorder (ADD) to asthma have      misshapen toenails, which are almost impossible to
   when the Egyptians buried their dead, they        been reduced or eliminated by getting homes          clear up. Some molds produce mycotoxins, which
   left food so the dead could continue to eat.      properly cleaned. A few years back very few          can even cause cancer. The most powerful
   The mold grew on this ready food source.          children had asthma. Today, many children have       naturally occurring carcinogen is aflatoxin, which
   Mold may have played a part in the Salem          it. Some teachers tell us that up to 50% of the      is produced by mold.
   Witch Trials. Mold growing on their bread         children in their classes have asthma. One teacher   The fact is that homes are built differently today.
   may have caused hallucinations in the             stated that there were more emergency inhalers in    And are molds ever glad. To save energy, homes
   children who accused people of being              her classroom then pencils.                          have been built tighter. Indoor air takes 5 times
   witches. Since the people of that day didn't      The biggest health problems occur from what          longer to exchange itself with the air outdoors than
   understand hallucinogenic chemicals, they         mold "gives off". There are chemicals called         it did 50 years ago. So toxins and mold products
   figured that it had to be satanic influence.      VOC's (Volatile Organic Compounds) and               are trapped and                        Cont on p 5
Medical-Legal Interface                                                                                                                               Page 5

                                                        Mold, Friend or Foe?
 Continued from page 4

   concentrated in the home. Add to that the
   chemicals we spray into our homes that
                                                                      Some Molds and the Diseases They Cause
   causes all kinds of diseases. We have
   created a pollution problem in our homes            Absidia - Skin eruptions.
   that rivals the most polluted cities in the         Acremonium - Skin infections as well as meningitis, arthritis and hard palate lesions.
   USA.                                                Alternaria - Skin, ear, nasal and pulmonary infections.
              If you read the EPA's                    Aspergillus - Pulmonary infections and blood vessel diseases. Possible cause of King Tut's curse.
   "Introduction to Indoor air Quality" manual,        Aureobadidium - Foot and leg infections.
   they tell you to use bleach on "non-porous"         Candida - Erosive skin infections, yeast infections.
   surfaces. They tell you to dispose of porous        Chrysosporium - General infections.
   materials contaminated by mold. Cleaning            Cladosporium - Skin infections, tinea.
   the surface of a mold colony doesn't affect         Coccidoides - Flu like infections and possible brain infections.
   the insides of the colony. Like an iceberg,         Curvularia - Mycetoma, endocarditis, pulmonary and nasal infections.
   most of the mold's colony is unseen, below
                                                       Drechslera - Meningitis, skin and nasal infections, peritonitis, and abscesses.
   the surface. In our case, below the surface
   means, "hidden inside the wall, floor or            Fusarium - Skin, bone, ear infections and skin ulcers.
   ceiling". And remember, the unseen part of          Microsporum - Tinea, mycetoma. Mucor - Ear infections.
   the iceberg sank the Titanic. Most                  Nigrosporum - Skin infections.
   commercial bleaches also leave a phosphate          Paecilomyces - Endocarditis, skin lesions, pulmonary infections.
   residue, which is like "mold fertilizer". Use       Penicillium - Skin and ear infections.
   of bleach can also lead to the formation of         Rhizopus - Ear infections. Scopulariopsis - Skin, lung and ear infections and skin ulcers.
   chloroamines, which can cause cancer. In            Sporothrix - Black, hard ulcers of the skin.
   addition, there are studies that show that          Stachybotrys - Lung disease, especially in children.
   chlorine bleach is toxic to humans,                 Trichosporon - Beard and mustache infections.
   especially to children. "Technology Review,
   Jan, 1995 v98 n1 p54(7)".

                                                       The Unasked Question
                                                   By Gail Hendrickson RN, CEN, LNC
    A 58 year old male arrives via ambulance to        increase his IV rate, and still no improvement.    too embarrassed to tell anyone. He doesn’t
    the emergency room. Upon the EMT’s arrival         His blood pressure is even lower now. He is        take it every day, only occasionally. He was
    at his home, he is complaining of substernal,      barely responsive at this time. His girlfriend     asked what medications he takes on a daily
    crushing chest pain, radiating to the left arm     arrives, and frantically comes into the room.      basis. The EMT didn’t ask before
    and jaw. He is sweaty, and complains of            The first thing she says when she comes into       administration of his first nitroglycerin. The
    feeling sick to his stomach. His initial vital     the room is “Honey, did you tell them you took     emergency nurse and doctor didn’t ask either.
    signs were 180/104, pulse 79, respirations 24,     Viagra last night?”                                It can be a very embarrassing question to ask.
    and Oxygen Saturation 98%.                         Everyone in the room feels sick to their           In our emergency department we now have
                When the patient arrives in the        stomach. No he didn’t tell us, but we didn’t       little signs above the patients head that say
    emergency room, the EMT gives his report.          ask either. We all know that medication used       “ASK AWAY” as a reminder to us to ask this
    He states that he has been in good health. His     for erectile dysfunction such as Viagra, Levitra   question.
    pain began suddenly, and woke him up. He           and Cialis can cause life threatening                          What are the legal implications of
    initially rated his pain a 10 on a 0-10 pain       hypotension when combined with nitroglycerin       this case? If you are reviewing a case in
    scale. He has no allergies, and his only daily     if. These mediations cause the muscles that        which a patient has had a bad outcome after
    medication is Pepcid for acid reflux. They         control the size of blood vessels to relax.        receiving Nitroglycerin, look back to see if he
    have administered oxygen at 3 liters via nasal     When these muscles relax, the vessels enlarge      has ever been prescribed a medication for
    canula, 4 baby aspirin, and one nitroglycerin.     in diameter, and as a result, the blood pressure   erectile dysfunction. Check to see if his
    He has an intravenous with normal saline           drops. When Viagra and nitrates are taken          prescribing doctor did proper teaching. Did
    running at 100 cc per hour. His pain is now 6.     together, the effects are greater than when        he explain the reasons he needs to tell a
                As you begin your assessment, you      either one is used alone. There may be a           health care professional that he was taking
    find his blood pressure is now 130/80, pulse       marked relaxation of the muscles that control      Viagra, if he is goes to the hospital with chest
    80, respiration 24, and oxygen saturation is       the vessels with a great drop in blood pressure.   pain? Where did he get this medication
    100%. His EKG shows ST changes, which are          A drastic drop in blood pressure is detrimental    filled? Are there warnings on the bottle and
    indicative of ischemia. He is still complaining    to patients who have angina, a condition in        on the patient information sheet? Was this
    of chest pain, so the emergency room               which a higher blood pressure is necessary to      question asked before administering
    physician asks you to administer another           supply the heart with blood. Lowering the          nitroglycerin? It is not safe to give
    sublingual nitroglycerin. Two minutes after        blood pressure decreases the flow of blood to      nitroglycerin if a male has taken Viagra,
    you have administered the nitroglycerin, he        the heart and can precipitate a heart attack.      Levitra or Cialis within the past 24 – 48
    tells you that he feels very lightheaded, and is              Why did this happen? The patient        hours. Any health professional who has been
    more diaphoretic. When you recheck his             may not have realized that he needed to tell       involved in a case like this, will never forget
    blood pressure it is now 90/40.                    someone he was taking it. He may have been         it. So before you give nitroglycerin, ASK
                You quickly put his head down,                                                            AWAY.
   Medical-Legal Interface

   Pattie Patterson RN, LNCC
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        Life Care Planner
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      Richmond, Va. 23228

       Phone: 804-262-2991
         Fax: 804-266-5701

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