MORE NURSING NOTES

It’s been enjoyable learning more aspects of public health nursing here in Barrow.  I mentioned in an earlier post that we have a close alliance with the Infant Learning Program Developmental Specialist who follows up with children who may have developmental delays or disabilities.  She invited the public health nurses to join her in two of her December teleconference sessions that are a part of the Developmental Disabilities class she’s enrolled in through the University of Alaska in Anchorage. 

Bertrand and I had just returned from the clinic in Wainwright, so we weren’t able to attend the one offered on Friday, 12/7.  The first part of the program had to do with fetal alcohol spectrum disorder and about how it is diagnosed.  The second part was an overview of developmental disabilities and metabolic conditions.  It was facilitated by a developmental pediatrician, Dr. Beth Ellen Davis, from the University of Washington.  It would have been interesting to attend.

On Friday, 12/14, all three of the public health nurses, Michelle, Bertrand and myself were able to participate in the session on autism screening using the assessment tool, M-CHAT (Modified Checklist for Autism in Toddlers) and autism spectrum disorder diagnosis in children two and under.  It was also facilitated by Dr. Beth Ellen Davis from UW.  It was interesting listening to how the screening tool is used and how autism spectrum disorder is diagnosed.  Currently public health nursing uses a screening tool called the Ages and Stages Questionnaire that we have parents fill out when we suspect a delay or disability of any kind.  The new screening tool can be printed and filled out by the parents or can be pulled up on our computers or Ipads (coming soon) and filled out during an interview with the parents.  This is a new system and is being tested, but has the potential to calculate scores and send those children’s results that are below normal to Infant Learning Program specialists for referral.  It eliminates hand calculating scores and paper referrals.  Bertrand is especially excited about the possibility of our using this new screening tool, so he’ll most likely take the lead and have us all up and running using it in the near future.  More about the M-CHAT can be found at http://www.autismspeaks.org/what-autism/diagnosis/screen-your-child, including:

Modified Checklist for Autism in Toddlers (M-CHAT™) is a scientifically validated tool for screening children between 16 and 30 months of age to assess their risk for autism spectrum disorder (ASD). It was developed by neuropsychologists Diana Robins and Deborah Fein and clinical psychologist Marianne Barton.

The American Academy of Pediatrics (AAP) recommends that all children receive autism screening at 18 and 24 months of age, and the M-CHAT is one of the AAP’s recommended tools.

The M-CHAT’s primary goal is to detect as many cases of ASD as possible. Therefore, there is a high false positive rate, meaning that many children who score at risk for ASD will not be diagnosed with ASD. To address this, the authors developed a structured M-CHAT Follow-up InterviewTM (downloadable here).

Even with the follow-up questions, a significant number of children whose results show risk for ASD will not meet the diagnostic criteria on a more comprehensive evaluation by a specialist. Nonetheless, these children are at risk for a range of developmental disorders and delays and, therefore, should receive further evaluation. Conversely, a child should be referred for further evaluation any time a parent or professional has persistent concerns about autism, even if the child does not show ASD risk on the M-CHAT. If you and/or your physician feel that further screening is needed, you can request a free developmental assessment through your state department of health.

I'd like to learn more about developmental disabilities...public health nursing is beginning to seem very broad with required knowledge in many areas.  I'm looking forward to attending Well Child training in Juneau in March, learning to do focused assessments and to use some of the screening tools.

I seem to be developing a reputation for being the expert on pertussis contact investigations.  I did a very long and involved one in October, so when we received lab reports last week and this showing two people positive for pertussis, they were both routed to me.  One must drop other tasks immediately and begin the investigation.  I completed them, each taking two days and was given quite a bit of praise from all of my colleagues.  I have a strong feeling that they’re all secretly smiling, thinking that I might actually enjoy doing them given enough positive reinforcement.  There isn’t a bone (verbal or otherwise) big enough though to make it a fun job.  It’s a sedentary, long and sometimes complicated process and doesn’t involve any direct patient care.  I finished the last case yesterday and have my fingers crossed that I can begin meeting with clients again and for a long time to come.  The health care providers at the hospital are now routinely treating close contacts with any signs or symptoms of pertussis with Azithromycin.  This should help prevent some of the contacts from contracting the disease and those who are carrying it, from spreading it. 

When not involved in a pertussis investigation, my mornings begin with reviewing the charts of the clients that Michelle is scheduled to see each day.  I love how she, Joanne and Bertrand have all encouraged me to not look at the area of each health summary that shows which immunizations are due, but to look at the child’s age and at the schedule of immunizations, trying to determine on my own what they are due for.  We had a puzzling chart last week that didn’t make sense.  There was no Hep B immunization recorded at the time of birth and no six week immunizations listed as given.  The infant had received his four month ones however.  After checking Vactrak, the Alaska State immunization data base, we were able to see that his first set of immunizations were given in Anchorage but were not on our RPMS data base in Barrow.  Michelle emailed someone at the hospital in Anchorage and was able to determine that the mother had refused the Hep B immunization at birth.  With this information and after the six week immunizations were entered into RPMS, the pieces came together.  It was a good example of why it’s important to critically think when reviewing immunizations that are due and not depend on the health summaries generated by RPMS as the nurse’s sole guide.

After reviewing the charts and sharing my findings with Michelle, she’s been giving me many of the clients of all ages who have come in for flu shots and adolescents that come in for flu, MCV-4 or HPV-4 immunizations.  It’s rewarding to feel independent and comfortable when meeting with them and their parents.  I weight and measure each client, striking up friendly conversations with them to establish rapport.  When in the exam room, I review their intake paperwork where questions related to domestic violence, allergies and adverse reactions to vaccines are answered, give them a VIS (vaccine information sheet) on each vaccine that will be given, and ask if they have any questions or concerns before drawing up the vaccines. 

The little four year olds seem to be most frightened of getting shots and am learning that coaching the parent on how to hold them, doing the shot quickly and rewarding with a ball, sticker and a tooth brush usually calms them quickly. 

Before leaving on Christmas vacation, Bertrand trained me to download the three thermometers in the two immunization refrigerators and freezer.  He does this each Monday, saving the results and then emailing them to the Vaccine Depot in Anchorage to verify that our vaccines are being stored within required temperature ranges.  We use data logger thermometers that have a USB stick on the top which are easily inserted into a computer.  Temperature recording is stopped and ranges on a graph for the last week are analyzed.  The procedure takes several minutes and is interesting.  I’m glad to be able to do it when Bertrand is out.

We were scheduled to work on Monday, December 31 and have Tuesday, January 1 off, but received a memo from North Slope Borough Mayor, Charlotte Brower, last week letting us know that she was giving us Monday off as well.  Today we received another memo letting us know that we could leave work at 1 pm this afternoon.  Our schedules were booked with multiple clients until late in the day so Nellie, the front desk scheduler (among many other things) did her magic, calling each of them to see if they wouldn’t mind coming in in the morning instead.  Everyone was happy to comply so we jumped into action and took care of them all with the last one leaving shortly before noon.

The office I share with Bertrand is comfortable most of the time, but some days I feel cold and he feels hot.  He understandably opens the window and turns on the fan and I don my fleece and turn on the small portable heater under my desk.  Last week he commented on how puzzled he was that the room felt so different to both of us.  He happened to look under his desk and realized that a baseboard with a large surface area, giving out quite a bit of heat, ran along his its entire length while mine was against a bare wall and got the direct draft from the window.  We agreed that it might be a good idea to trade desks.  He is away for Christmas but gave me the OK to do the job if I wanted over the holiday.  With the afternoon off and the music on I did the switch.  I was relieved when after dusting, rearranging and finally trading our computers, that they both worked and that by changing telephone cords, we would be able to keep the same extensions.  A great end to the week and hopefully the beginning of a more comfortable work space for both Bertrand and me.