The tapestry of the life of a medically complex family

Archive for the ‘Nursing’ Category

Home Nursing Racket

Those who follow my blog know there are blessings & challenges with regard to home nursing when you have a child with complex medical needs who requires skilled nursing care. The blessings are few, but GREAT when they are found. I am so very thankful for the one nurse I have who brings skilled care & love to my children the only 15-29 hours of care I have covered each week. My children are approved for 133 hours per week each. I have 29 covered AT MOST.

None are night hours. I spend way too much time awake every day (19-23hrs, depending) to get anything but the basics & medical care done for my children. We love & laugh each day, but it is medically focused since I have no help.

Last week I met with a 2nd agency trying to get more help- and maybe some sleep. Family Lives claims a family & patient-centered philosophy, a “designed by parents” history. My experience was one of the many “worsts” in the history of my children with trachs being home.

The person assigned to us arrived at my home 15 minutes early for our meeting. I asked her to come back at 9. My kids were still at the table eating breakfast-the table where we would be meeting- and I was on the phone fighting to get a feeding pump cord replacement with our equipment company, who had no record we HAD a feeding pump. As they knocked my SIL had texted to tell me that our much loved dog’s “pup-mate”, who had been owned by my Mom, had died overnight. Bad timing. When you are coming to someone’s house for the first time, be on-time, not early.

They decided they would go & come back around 9:30. (It was supposed to be ONE person, she brought a second unannounced.) They opened their visit with judgement: “WOW! That is a BIG dog!” says 1. Says 2: “we let our first dog get really fat, but we aren’t making that mistake with our new dog.” … How do you respond to THAT? ‘Welcome to our home’???? Yep. It started off “fun”.

Then the 2 proceeded to pepper the usual questions back-and-forth: diagnoses, treatments, responsibilities… Then SHOCK to find out my son was a “full code“… uhm, he’s going to be 8. Yes there is an unclear metabolic disorder result, but letting him die, not really part of the plan right now.

Then they continue with release forms & are dismayed at my lack of trust for free access to any & all doctors whenever they want. They have a right to contact a doc about an order, to connect with my pedi, I have no responsibility to give them free access to EVERYONE at ANY time. That’s how care plans get screwed up by people too lazy to do the work. They can absolutely have my as needed permission to contact a doctor, but not cart blanche.

Then the women commented how cold my kitchen was. We had been sitting in an 80 year old kitchen addition, off the back of a 200yr old New England home, which is not incredibly well-insulated, on pretty much the COLDEST day in January so far. I told them yes, my kitchen can feel cool- 62 degrees or so, but that our heating temps are dependent on our poverty & my son’s severe heat intolerance.

They ask about what I want a nurse to do if there is an emergency when I am not home. I tell them I want her to call me. They think I do not understand. With odd glee, #2 says: No. An emergency. You’re not home & your kid is CODING on the floor… Given that I tend to go as far as the grocery (1/4mi) and NEVER before I trust a nurse completely (3mos. or so)… Call me. And if she HAS to call 9-1-1, then do that next. They were surprised. I am sitting here wondering WHY they ASKED if there is only 1 answer… If they have a policy, state the policy & inform, don’t ASK the family.

On their way out, they asked about my children’s birth family, making conversation. I point into the living room where individual pictures of their older sisters hang next to photos of my children. They make a face looking at the giant pile of boxes in our unused living room. We received our supply orders during my recent 2 week span without a nurse, while my 3 kids were sick, BETWEEN recycle days. I explain yet another thing they judge & say my goodbye- HOPING they find less judging nurse staff to help our family.

Yesterday #1 calls to inform me that they REFUSE to take our case on, BECAUSE OF THE TEMPERATURE OF MY HOME. There is no discussion. Just a “refusal” of our $800,000 annual nursing contract. I explain to her again the costs ($600/January) and the fact that my son suffers breathing fatigue & respiratory distress at temps above 70 degrees. #1 says: I understand. But that makes it an inappropriate environment for our staff.

I think she needs to look up the DEFINITION of the word ‘understand’.

They came into my home & found a family hanging on to the knot at the end of their rope. And they chose “judgement” over “support”…

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Night Nurse Day

With my trached twins & youngest with breathing, GI, ortho & neuro challenges, you can imagine my house is a pretty busy place. The twins are approved for a lot of nursing hours but on average I get 20hrs of coverage. There are school vacations, special training at their “day job” & a host of other reasons a nurse might miss multiple shifts a month.

Since July, I have only met with one nurse referred by the agency. He was “miraculously” unavailable for ANY shifts I wanted filled & only ones that were partial & inconvenient (come after & leave before meds…?) as soon as our 4hrs of training him had ended. I have not had a single night of nursing since late July. It is now late January.

For me, it wouldn’t seem so bad if it wasn’t for the fact that my kids have been sick for FOUR FULL MONTHS of that six months. They went on “sick plan” the first week of August & stayed on it through October- with 10 inpatient days in September for all 3. They took antibiotics & long steroid tapers & finally seemed “better” the first week of November.

After about 2.5 weeks of regular meds, “sick plan” was reinitiated. More steroids after an ER visit for one, antibiotics for 2. We stayed home for Thanksgiving, unable to pause nebulized meds longer than 4hrs apart.

Maybe things are not clear to everyone but “sick plan” is a MINIMUM of 2-3 nebulized medications, 3 times daily. The minimum is 8 nebulized medications per child, times 3 children. (When a nurse comes, s/he covers 6 for 2 of the kids, max). Most of this fall, the kids were on additional nebs- every 4-6 hours for bronchodilators, and 2hrs for normal saline nebulized in between for the twins during the day- and some nights but then we went inpatient. There are the regular oral meds too & additional doses of steroids and antibiotics.

And there’s cooking & cleaning & reading & laundry & bedtime & cuddles…

Yah. Exactly.

So when a nurse came last night- because our 28hr/week day nurse has been out sick half every recent week… Some friends thought I’d fall dead asleep & not wake up until he was ready to leave. No. Such. Luck.

After 6 months of 20-hr days, there is no “instant off”. I actually had a HARDER time sleeping than usual because I wasn’t in the same room as the compressors & alarms & cacophony that usually lulls me into my 3-4 hours/sleep a night. Last night I got less than 3.

Hoping for a nurse on Friday…

Today’s LAST Nerve

MY LAST NERVE?

When my nurse comes in coughing, I ask her to wear a mask, and she says:

“I think I got this from your (trached) son. Your kids are the only sick people I have been around.”

RUFKM?!?!?

She lives life in a world where the cold my kids have is a sniffle, that cough in the grocery check-out, just a TRIFLE.

It only looks major here because my kids get, & hold onto, & SUFFER from colds because of their CRAPTASTIC respiratory status.

WHY do people who are intended to be our HELP, also HURT?

Going to make coffee. And mutter in another room.

I know how lucky I am

Every day we struggle financially. Each day can be a physical marathon. But everyday I look at my Fearsome 3some and my college-attending teen, I know how lucky I am.

My oldest arrived at a time that may have been “less than ideal”: I was between Grad School Graduation & my first job in a new city- Philadelphia. I signed up to be a control on a “Core Temperature in Depression” study, recruiting non-pregnant females for $75 to swallow a silicone bean & wear a monitor. Imagine my 24-year old surprise! It was a roller-coaster but the answer to my dream of becoming a mother.
My son’s arrival was a flurry of NICU docs, worried nurses & labor-enhancing drugs. He arrived via vacu-assist (appropriate give his surname) and blinked at everyone like: What’s all the fuss? I’m fine. Parenting him was easy & carefree as I look back- but seemed every bit the struggle of every parent as I went through.

When he was 12 years old, my other mothering wish came true: he would have siblings, a brother & a sister, and they would join us in a new home I was able to purchase. His big heart and caring nature were so evident as soon as his brother & sister arrived. When his youngest sister came home, his heart swelled even more. It was amazing to watch & I could not ask for a more clear indication of parenting “success”.

The twins & my youngest may struggle with medical needs, feeding & energy but make up for it in the breadth of their capacity to love, endure & enjoy. They wake each day & immediately check-in with each other. Any separation (like taking my youngest with me to the grocery when a nurse is here with the twins) is predicated with a group hug & concludes with a reunion worthy of a Disney production.
Right now they are sitting at the kitchen table drawing plans for a Leprechaun Trap and sharing their ideas with each other. Yes, there is bickering over who has the box of crayons, which idea is best for the trap, what a Leprechaun will do if they don’t wear green… But most of the interaction is give & take of ideas, punctuated with positive encouragement of “that’s a good idea!”

Medical needs aside, I may be the luckiest mother in America.
(See what 4.5 hours of sleep does for a person?!)

The Best of Nursing

Some of our home nurses have been wonderful home nurses. These women & man have worked tirelessly to provide my kids the necessary medical care, caring and developmental support in the best of all possible ways. When my children first came home, they were 2- and then 3- VERY complex, fragile infants. At 15 months old, my twins wore 6mos sized clothing, their trach masks were nearly the size of their heads, and only my daughter could make sounds and crawl.

Nurses came into my home and were trained to change a trach in less than 20 seconds because my children could get no air in without the tube in their neck. They were taught to suction for less than 10 seconds and at a very specific depth, lest they collapse one of my children’s miniature lungs or cause more damage to the trachea. My kids were problem feeders, constant vomiters, attached to multiple pieces of medical equipment all day and these nurse came to work on the front lines of my kids’ medical care to help me keep them home, keep them safe and succeed as a family.
Who were/are the successful ones? The successful ones are nurses who have good, basic clinical skills. They can auscultate lung sounds and differentiate wheezes from crackles from rhonchi from a pleural rub. They know to count heartrate & respirations for a full minute with young children. They know to give a child a minute to cough & clear before heading straight to suction. They can watch a child at play in their fleece outfit and know their respirations are above normal and they’ve begun retracting- before lifting the shirt to count & see.
These nurses also have the ability to LISTEN. They take direction from the parent while following the orders of the doctors. They measure carefully when using a graduated suction catheter. They remember this is “home”, not “hospital”, so they take the time to play, to laugh, to sing, to enjoy. They follow through on exercises, strategies, procedures and activities that help the kids move forward in their development, while continuously monitoring and assessing their health status.
These nurses also have communication skills in the area of bringing information to families. They sometimes come with other experiences or discover a more effective way of doing something. They might have new medical information about a child’s diagnosis or information to share about a medication. They are able to talk with a parent without talking down to a parent. They give information that supports more effective care of the kids, better quality of life.
I have appreciated every minute of support from these nurses. I have worked to be sure they know how much they are valued. My children have thrived under their care & with their support. Many of these people have had to move on with their careers, their lives, but we still think of them often and cherish their support in this complex medical life.

10 Things about Home Nursing

… That I wish could be learned by reading a list & not having to endure it.

10. Home nursing often attracts the dregs of the profession. Families count narcotics, ADHD meds, pain pills- consider a lock box to which you have the only key.

9. Home nurses may misplace, damage or ruin things in your house and never admit to having done so.

8. Home nurses are NEVER on time and rarely go a month without missing a shift.

7. Home nurses can rarely identify a trach or GTube from an array of medical equipment and plumbing supplies.

6. Home nurses bad mouth families as often, if not more than, families express disdain for their performance.

5. Home nurses rarely have the assessment skills to determine when medical follow-up is needed.

4. Home nurses rarely have any skill which they can “instruct the parent” to support the parent’s ability to better maintain their child at home.

3. Home nurses rarely LISTEN and COMPLY with medically sound advice or procedures which have proven successful for a child in the past, if this information is shared by a parent.

2. On a rare occasion, your family may truly be blessed with a professional nurse who is a shining beacon of skill, caring and support to a family with a child with complex medical needs.

1. If you find your beacon, HOLD ON TIGHT: support them, be flexible, make tea, make coffee, celebrate birthdays, celebrate Tuesdays, bake cookies… Keep looking & sorting through the rest until you find them.

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