Archive for April, 2010

Medical Malpractice related to nosocomial MRSA infections, comment

April 28, 2010

After reading the 1/16/2007 post regarding nosocomial infections especially with MRSA, I had to respond. I think hospitals all over the US need to adopt what the hospitals are already doing in Europe. The nose swabs are a fast and effective way of determining whether a pt is at risk or not for MRSA. Many pts prior to leaving the hospital setting, suffered from MRSA which became very demanding for the nurse and ancillary staff to care for. Pts were placed on isolation and had to go into the room completely gowned up which requires extra steps to an already busy schedule for a 8-12 hour shift. This testing would also maintain the reimbursement Medicare gives hospitals because as of October 2008, it was determined by COHIaBA, who governs Medicare stipulations, would be taking away money from the hospitals if pts were diagnosed with MRSA or greater than Stage 3 Pressure Ulcers. THis would mean a greater reimbursement which would help maintain staffing and salaries to nurses and other ancillary staff. I think this is a great idea to assist with the on going changes with health care that this country is going through right now.

Original Post
January 16, 2007
Title: Medical Malpractice related to nosocomial MRSA infections
The media and government have educated the public in the “super bugs” some patients become infected with in the hospital environment. The most widely known “super bug” is methicillin resistant staphylococcus aureus (MRSA). In June 2006 there was a case brought to court regarding the death of patient who had been in the hospital for a knee joint replacement. Since the patient had not been screened for MRSA prior to hospitalization it could not be proved if he picked up the MRSA during the hospital stay. With the documented community acquired MRSA he could have had the bacteria dormant in his body when he was admitted for the planned surgery. The doctor and hospital were not found negligent in this case.

Many hospitals are fearful of similar lawsuits based on nosocomial infections. Some hospitals are now culturing high-risk patients prior to hospital admission to determine if they are colonized. There is now a nasal swab test that has a turn around time of two hours to identify MRSA. Certainly this can be helpful so that colonized patients coming in for elective procedures can have this treated and also be isolated from non-colonized patients. Patients that test positive for MRSA can be cohorted with like patients or put in private rooms. There are multiple hospitals in Europe starting to follow this intervention with positive outcomes in their nosocomial rates.

It would seem to me the hospital administrators would prefer paying for the MRSA culture versus facing the potential of law suits from patients who develop nosocomial MRSA infections while inpatient. If I had a family member going to the hospital I would much prefer they be tested for MRSA prior to a surgery as “knowledge is power” Having the knowledge of colonized MRSA prior to surgical intervention can allow for adjustments that lead to positive outcomes for the hospital, surgeon and patient. I can visualize hospitals even being forced to do it to allow them better leverage in the court system by being able to say, “this person was colonized with MRSA” prior to hospital admission. From the epidemiology stand point it would also allow the opportunity to keep the more virulent strain of community MRSA from entering the hospital environment.

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Substance Abuse, comment

April 26, 2010

I wanted to respond to the post regarding substance abuse and how it can be detrimental to other forms of abuse. What I want to discuss is when the nurses are abusing substances. Several years ago, while working on a med surg floor, I received report from the nurse coming off the shift who was, based on my assessment, was under the influence. The nurse had pin point pupils, had slurred speech and a bandaid over an area on left hand with fresh blood noted. Upon the initial assessments of my pts, all that had the nurse I had received report from where rating their pain greater than 6/10. Upon review of pyxis machine it was determined that all pts had medications every six hours as ordered but all state they did not receive meds through the night. I handled this situation by meeting with my supervisor and instructing her on talking with the nurse prior to her going home to see if she saw the manifestations I did. We as nurses need to perform assessments on each other to insure we are being pt advocates, as well as team players with other nurses if they need assistance with any substance abuse.

Original Post
December 30, 2009
Title: Substance Abuse
Although there are mild cases, substance abuse can be a major problem that leads to other issues such as child abuse, elder abuse, or sexual assault. These issues are reasons that make substance abuse a serious problem. Substance abusers should put this under control as soon as possible. Alcohol treatment programs are designed to help those that want and need help be successful at this. As a nurse, assessment skills are imperative in diagnosing a substance abuse problem. Skills in the assessment of mental health cannot be forgotten, since they focus on emotional and psychological well being. A good mental health assessment could reveal the underlying problem(s) of substance abuse.

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Medication errors haven’t been reduced with electronic med administration in my facility

April 26, 2010

With the start-up of EMAR (electronic medication administration record) in my facility in November 2009, we were certain of improving med administration and reducing errors. I also assumed Pharmacy would be able to deliver the new meds ordered to the floor sooner. Not so….it actually has been taking Pharmacy longer to profile the med orders. And the number of profiling errors has not reduced. It still falls on the shoulders of the harried floor nurse as the last set of eyes, to catch errors. Now I’m hoping Physician electronic orders will be the solution. Let’s just hope we get to the end point we so desire, for the patient’s sake!

Original Post
March 31, 2010
Title: 200,000 Americans killed each year in hospitals by medical errors, comment
I definitely think this is a drastic number and being on the front lines, I can see how this happens. Especially in today’s ever changing healthcare field. First, you have EMR which has completely changed our world. There have been so many changes recently that it is very hard to keep up with it all. Not only they way we chart things, but how we administer medications. Caremobile, the pt scanning device, is supposed to help catch errors. But with the Electronic charting, the charts and orders are not getting checked like they were because it is too difficult to do and navigate around. Not to mention that there are alot of issues with connectivity, timeliness of entering meds by pharmacy, etc. That by the time the med could be given, alot of unnecessary time has passed, so you may just do a work around to get the task accomplished which defeats the purpose of using Caremobile to begin with! Throw long hours, after hours "catch-up", high acuity, understaffing, and a whole slew of other issues that are dealt with daily, it is easy to see how these unfortunate things could take place. I definitely think that issues that are causing unnecessary deaths should take precedence over anything else. And fix what is the current problem before you add something else into the mix.

Original Post
March 29, 2010
Title: 200,000 Americans killed each year in hospitals by medical errors, comment
There is no simple answer to why medication errors occur. People die every year from preventable medical errors; wrong limbs are amputated, wrong organs removed, people receive the wrong medications, orders are incorrectly transcribed, medication reconciliation is often flawed, the list could go on forever. Errors are a result of human nature. While every effort is made to minimize and prevent errors, they still occur. Nursing education, annual and ongoing review of the Joint Commission National Patient Safety Goals, time outs prior to surgical procedures, are all great ways to work to prevent errors from occurring. Responses to errors should not be punitive; they are situations from which we learn. Errors result because processes fail.

Original Post
March 4, 2010
Title: “200,000 Americans Killed Each Year in Hospitals by Medical Error”
Listed in the above are common causes of medication errors: lack of sleep in caregivers, poor communication, illegible handwriting, poor staffing. These problems are encountered in all areas of patient care. There are never enough nurses, nurses have too many patients, work too many hours, and in reality are often rushed . Home medications are often not reported accurately and many physicians (who are also often rushed) write poorly. Several of the 2010 National Patient Safety Goals focus on medication administration as a result of reported medication errors. How do we change this? Change begins with education. Nurses must continue to learn about new medications and review old ones, never hesitating to consult resources if unsure about any aspect of a medication. As the last line of defense between the patient and a medication error, nurses must be dedicated to practicing the 5 Rights and the nursing process as it relates to medication administration, providing thorough assessments and evaluations even when rushed. Patients must be educated as well, and taught to ask and know about their medications, to report untoward effects and to learn about lifestyle changes which could reduce or eliminate the need for some medications. As nurses, we must continue to promote better nurse to patient ratio in all areas of care. We must exhibit professional and safe medication administration in our own practice and in mentoring new nurses just beginning their profession. The amount of reported medication errors is a sobering fact which should incite a call to all nurses and facilities to performance improvement in this area.

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Suicide versus Hospice Care, comment

April 21, 2010

Many patients receive the diagnosis of cancer as a death sentence, even though advances in cancer therapy are occurring almost daily. Cancer is a disease that is non-selective in its victims, striking all ages, all nationalities and all socioeconomic areas. When a patient receives a diagnosis of cancer, it causes him to face his mortality – and often brings regrets of previous life choices. What can we as nurses do to help our patients receive a cancer diagnosis with hope and courage, rather than doom? First, we can teach; prior to diagnosis, each patient in our care should receive teaching on preventive measures to reduce cancer risk – diet, exercise, smoking cessation, screenings, etc. Second, when the physician tells the patient he has cancer, we can reinforce and teach on the interventions recommended by the doctor. This would include encouraging the patient to express his fears and concerns, and through patient teaching helping to reduce them. If the physician recommends surgery (tumor excision, debulking or palliative) we must address the concerns of anesthesia and pain management, both typical areas of patient fear. If chemotherapy is recommended, sometimes the fear might be as basic as alopecia or nausea and vomiting secondary to chemotherapy. We can assist the patient in choosing a hair piece prior to hair loss, and explain the regimen of combination antiemetics (i.e. aprepitant, dexamethesome and ondansetron) prior to the start of chemotherapy. When the patient is admitted to the hospital for chemotherapy, we must administer medications on the exact time schedule ordered by the physician, especially important in cytotoxic agents which act in a specific phase in the cell cycle. Cancer therapy can be extremely complicated, and nurses must teach the basics in terms that are both understandable and gentle, by choosing our words carefully. Thirdly, we must teach on the decision to treat (or not treat). Most patients perceive chemotherapy as highly toxic and damaging, and fear what it might do to normal cells. The patient must be given an idea of projected benefits versus risks – i.e. cure, palliation or extending a life that’s functional though not cancer free. If they are diagnosed with a highly responsive cancer, we must encourage them to treat, but the ultimate decision is theirs. If the patient decides against treatment, and Hospice is recommended, we must teach about Hospice care and approaching death with dignity. Most Hospice agencies have printed literature outlining pain management and services offered by Hospice (counseling, social services, pastoral care, etc.) for both the patient and the family. With a cancer diagnosis, comes the stages of grief. Nurses have a great responsibility to help the patient move through the stages of grief to acceptance,in a way that is empathic and supportive, but never encourages the option of suicide.

Original Post
April 10, 2010
Title: Suicide versus Hospice Care
What does it say for us as health care providers when a patient who receives a diagnosis of cancer commits suicide? The thought of enduring treatments without cure, suffering physical pain and medication side effects, not to mention facing one’s own mortality, can sometimes push even an individual over the edge. I have to wonder whether we are truly meeting the needs of our patients when I hear that someone has committed suicide because they couldn’t deal with the thought of dying a difficult death. And why does any death need to be "difficult"? It is sad that people perceive hospice as "The Grim Reaper coming through the door with a sickle and shroud to kill you with their morphine". Sadly, this perception is not limited to patients. Medical professionals are in serious need of education about end of life care and pain management and symptom management for a family to hear "you have to give up everything in order to be eligible for hospice" or "hospice means you’re dying" from a medical professional feeds the fears and stigma associated with the very term. Suicide should never be a mechanism in which to manage a life limiting illness. Should people choose to hear, they would learn that hospice can provide them excellent symptom management, allow for life closure, and place their needs at the center of care. Death can be peaceful, serene, and dignified. It is only difficult when fueled by ignorance.

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Monitoring Patients on Pain Medication, comment

April 19, 2010

With more and more people under pain management care overdose of medications is becoming more frequent. As nurses we have to be aware of the medications given very freely by pain management doctors and how to treat overdoses quickly. We see this everyday in the ER. It is unfortunate for the patients because the first thing we do is reverse the drug. This creates anxiety and pain for these patients. So education for the patients and the families is very important.

Original Post
March 21, 2006
Title: Monitoring Patients on Pain Medication

When monitoring patients on pain medications, such as morphine, dilaudid, and demerol; it is important to make sure that certain side effects do not occur. It is very important to monitor the respiratory status because decreased respiratory status is one of the main side effects that can happen from giving pain medications.

Narcan is another medication that it is important to be aware of. In one case, a patient was having apneic spells for about 30 seconds at a time and I had to administer narcan two times within a half an hour. I had my doubts about narcan through my readings, but seeing it personally really made me a believer. A simple medication can reverse respiratory depression and help the patient have a normal respiratory status.

It is also important to educate patients about pain management at home. When patients are taking pain medications at home, there is not a nurse or a physician there that can help if something goes wrong.

The main area that needs to be covered before discharge is side effects that need to be reported and the right dosage amounts that can be taken at certain times. Make sure that the patient is very knowledgeable about the medications they are taking and that they know when to call a physician or nurse when something is not right.

Pain medications are a wonderful thing, but can have their side effects that are not so good. However, by keeping a good eye on your patients and making sure that their vital signs are stable you will help the patient have a quicker and less painful hospital stay. Also, make sure that patients know what medications they are taking and what side effects may happen as a result of the medications before leaving the hospital.

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Falling Accidents and Seniors from a Forensic Nursing Perspective, comment

April 19, 2010

As a nurse in the ER we see most of our falls from seniors being over medicated. They are being treated with medications that slow them and alter their thought process such as for depression, insomnia, and a many other disorders. When we do our fall risk assessment it is amazing at how many medications they are on and put them at high risk. Many are on Xanax just because they have trouble sleeping instead of trying to figure out the problem. I feel this is way too much for most.

Original Post
February 13, 2006
Title: Falling Accidents and Seniors from a Forensic Nursing Perspective

I took great interest in an article in our local newspaper last weekend. It alluded to the fact that falls were causing an inordinate number of deaths in Minnesota and Wisconsin among senior citizens. At first glance, we might conclude that our winter weather with ice and snow was a
causative factor, but this has not proven to be the case.

There seem to be other factors in play here. Of 1564 Minnesota elderly who died from falls, only 21 died of snow and ice related falls. Some of the theories being discussed are around the cold weather causing blood to become more viscous, thus contributing to the formation of clots
which then dislodge and deposit in vital organs.

Others speculate that the low light conditions of winter contribute to accidental falls, especially for seniors whose vision is declining or who may be wearing multiple focus lenses in their glasses. There is also speculation about the reactions to some medications, decreasing alertness in some and maybe causing dizziness and unsteadiness.

Those studying this issue stress that seniors should get help in their environment so that throw rugs and multiple barriers to safe walking are not contributing to falls. They also stress that slowing down and not hurrying are very important. And exercise so keep balance and joint
range of motion optimal is very important.

As to why this is all happening in Minnesota and Wisconsin, I offer the theory that we are an
independent breed of people, trying to do for ourselves without asking for help and maybe taking risks that aren’t necessary.

I can recall coming upon my 92 year old mother balancing on the arm of the couch to reach a tall cupboard. She was independent and hardy and also in very good health, but with the risks I saw her take, she was also a lucky lady not to have an incident that could have caused a decline in her health sooner.

All the normal factors of aging play into the broken bone theory, such as osteoporosis and unsteadiness. But thus far they are only theories and maybe further studies will yield answers in the future.

Any other ideas about what may be causing so many falls among seniors?

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Elder Abuse, comment

April 19, 2010

I wanted to post on the subject of elder abuse and how important it is to do a very thorough assessment when admitting a patient to the hospital who you suspect might have suffered some abuse. I work in an ICU unit and we received a patient from home who was bed bound and had several strokes in the past. He was being cared for at home by his wife. She also was taking care of two mentally handicapped adult children in their home as well. Upon admitting him to the hospital, we found that he had two very large areas on his buttocks directly beside his coccyx. They already had eschar on them. We immediately took pictures of the wounds. When the wife came in to see the patient, we asked about those areas and described them to her. She immediately became defensive and asked if we were accusing her of neglect. We told her that we were not accusing her of anything, but that we had to document any present on admission findings. She became very irate and demanded that she speak with the doctor. After talking to the doctor, he assured her that maybe that happened on the "O.R. table and that we would just treat the pt. The patient was only in the OR for an hour and a half so it seemed unlikely that this happened there. The wife stated that he was "not like this" when he came in and therefore, we must have caused them. There was an investigation and APS became involved and did find that there were some issues in the home. Had it not been for the assessment and documentation of the admitting nurse, then we may have thought that those wounds may have happened in the OR and not at home like they really turned out to be.

Original Post
April 14, 2010
Title: Elder Abuse
I wanted to comment on the importance of the assessment facilitated when the skilled nurse performs a head to toe on the elderly client. The skilled nurse not only has a responsibility to assess the body, but the holistic aspects of that client. I am a home health nurse, so from my perspective, the head to toe is a portion of the bigger scope of what I need to address. As we move into this new millennium with advances in technology, we are learning that the geriatric population is growing. More older adults are being placed in the position of caring for aging parents which can, for some, be an extreme balancing act to between their own lives and responsibilities, coupled with caring for their parents business affairs. All of these dynamics can place stress to that child of the older adult. Some of the abuse we as healthcare professionals need to assess is emotional and financial. Some parents, based on my experience, are made to feel guilty when the child needs to pick up a prescription or be taken to the doctors office. We need to ensure that the caregivers have as much support available to them to decrease stress, and increase the relationship dynamic between client and caregiver which will in part, keep the client healthy knowing that they have a good support system.

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Medical Malpractice Related to Nosocomial MRSA Infections, comment

April 15, 2010

Although this entry was posted in January, 2007, nosocomial infection is still a political and safety topic in today’s health care. Reduction of health care associated infection is one of the 2010 National Patient Safety Goals, and MRSA is still a great concern in all areas of health care. It is present in all avenues of society and especially in close living conditions such as prisons, nursing homes and group homes. Most health care workers have been exposed to active MRSA infections and many are colonized as well as patients. According to the CDC "Campaign to Prevent Antimicrobial Resistance" (2002), health care practitioners are to use antibacterials wisely; yet many patients are still being treated for specimen contamination, and colonization as well as in the absence of a positive culture and for extended periods of time. Vancomycin is the drug of choice for active MRSA, and though it used to be a "last resort" drug, it is now frequently given. This is a potentially toxic drug with some serious side effects. Given IV it can cause a systemic reaction of hypotension and shock-like state with flushing (red man syndrome) and it is irritating to the vein, frequently causing thrombophlebitis. Ototoxicity can occur and is more probable with high doses and increased duration of therapy. Vancomycin can be nephrotoxic and should be used with caution in renal impaired. As stated in the above CDC publication, practitioners must "know when to say no to vanco." When it is ordered, nurses must be aware of meticulous infection control, using appropriate personal protection and educating patients and families on MRSA and infection transmission. IV sites must be monitored and changed frequently, and vancomycin infused at an appropriate rate. The patient must be monitored for side effects and toxicity and vancomycin peaks and troughs should be monitored. As nurses, we are called upon not only to help our patient heal, but to do our part in preventing infection transmission, not only in the hospital, but in all aspects of care.

Original Post
January 16, 2007
Title: Medical Malpractice Related to Nosocomial MRSA Infections

The media and government have educated the public in the “super bugs” some patients become infected with in the hospital environment. The most widely known “super bug” is methicillin resistant staphylococcus aureus (MRSA). In June 2006 there was a case brought to court regarding the death of patient who had been in the hospital for a knee joint replacement. Since the patient had not been screened for MRSA prior to hospitalization it could not be proved if he picked up the MRSA during the hospital stay. With the documented community acquired MRSA he could have had the bacteria dormant in his body when he was admitted for the planned surgery. The doctor and hospital were not found negligent in this case.

Many hospitals are fearful of similar lawsuits based on nosocomial infections. Some hospitals are now culturing high-risk patients prior to hospital admission to determine if they are colonized. There is now a nasal swab test that has a turn around time of two hours to identify MRSA. Certainly this can be helpful so that colonized patients coming in for elective procedures can have this treated and also be isolated from non-colonized patients. Patients that test positive for MRSA can be cohorted with like patients or put in private rooms. There are multiple hospitals in Europe starting to follow this intervention with positive outcomes in their nosocomial rates.

It would seem to me the hospital administrators would prefer paying for the MRSA culture versus facing the potential of law suits from patients who develop nosocomial MRSA infections while inpatient. If I had a family member going to the hospital I would much prefer they be tested for MRSA prior to a surgery as “knowledge is power” Having the knowledge of colonized MRSA prior to surgical intervention can allow for adjustments that lead to positive outcomes for the hospital, surgeon and patient. I can visualize hospitals even being forced to do it to allow them better leverage in the court system by being able to say, “this person was colonized with MRSA” prior to hospital admission. From the epidemiology stand point it would also allow the opportunity to keep the more virulent strain of community MRSA from entering the hospital environment.

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Elderly Abuse

April 14, 2010

I wanted to comment on the importance of the assessment facilitated when the skilled nurse performs a head to toe on the elderly client. The skilled nurse not only has a responsibility to assess the body, but the holistic aspects of that client. I am a home health nurse, so from my perspective, the head to toe is a portion of the bigger scope of what I need to address. As we move into this new millennium with advances in technology, we are learning that the geriatric population is growing. More older adults are being placed in the position of caring for aging parents which can, for some, be an extreme balancing act to between their own lives and responsibilities, coupled with caring for their parents business affairs. All of these dynamics can place stress to that child of the older adult. Some of the abuse we as healthcare professionals need to assess is emotional and financial. Some parents, based on my experience, are made to feel guilty when the child needs to pick up a prescription or be taken to the doctors office. We need to ensure that the caregivers have as much support available to them to decrease stress, and increase the relationship dynamic between client and caregiver which will in part, keep the client healthy knowing that they have a good support system.

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Second puzzling case of autism reported, comment

April 12, 2010

Over the course of five years that I was an infusion nurse in a naturopathic medical clinic, I saw several cases of children with autism. These children often had one or several forms of heavy metal poisoning mercury and other metals. When treated with IV chelation these children improved drastically. Most of the history assessments revealed vaccines as the only source of mercury poisoning that was a definite factor.

During the course of the IV chelation and nutritional IV supplementation that went along with this, colonic irrigation was ordered to rid the body of metals that were being chelated out and adhering to the wall of the colon. Interestingly enough with these colonics, parasitic infestations were sometimes noted. Along with the chelation, natural antiparasitic botanicals and homeopathic remedies were given with an even more profound improvement in childrens behaviors related to the autism occured. So much that I intend on testing my autistic and even ADD and ADHD children not only for heavy metal poisoning but comprehensive stool analysis from a private lab when I start my practice.

It is a shame that alternative and what some refer even to "fringe" type medical treatments cannot be better studied in this country mostly due to non-acceptance my the traditional medical community and government funding for research.

I also feel, not only the mercury factor in vaccinations can be harmful but also live/attenuated viruses can become active in some sensitive individuals and possibly these illnees we are are trying to prevent are manifesting and effecting the brain and this is not detected ever or until after profound damage is done and the vaccine may not even become a consideration.

Original Post
November 26, 2009
Title: Second puzzling case of autism reported, comment
As governmental funds for researching the causes and eventual cure of Autism increase, it has naturally gained more attention from the public. I agree that this has its pros and cons. More parents are considering the possible ramifications of dosing their children with multiple vaccines. Parents are becoming more proactive and accountable when it comes to decisions regarding the medical care of their children. It is shedding light on a disease that has been, up until recently, misunderstood by most. On the flip side there isn’t a whole lot of concrete evidence linking autism directly to vaccine administration, yet there is a multitude of evidence that suggests that vaccines have saved lives, prevented the spread of potentially fatal disease and in some cases has eradicated the disease all together. I have a family member that became adamant that her children were never going to receive any type of vaccine – she executed extensive research on vaccines and homeopathic alternatives. To date her children have not received a single vaccine, they take multiple vitamins and herbal supplements on a daily basis and their diet is quite restricted. Sadly and ironically, her 13 year old son was diagnosised with autism at 3 years old.

Original Post
July 1, 2009
Title: Second puzzling case of autism reported
Federal health officials at an upcoming conference the controversial cases of a 9-year-old girl who became autistic after receiving numerous vaccinations. In January a 6-year-old girl received a flu vaccine and a week later became ill requiring hospitalization and ultimately died. Study after study has failed to show a link between vaccines and autism but many parents of autistic children claim that childhood vaccinations they received are responsible. In 1986 a National Vaccine injury compensation program was introduced to compensate injured children from vaccines. Many deadly epidemics have been prevented by vaccination. For the parent of a child injured following vaccination, grief and ambivalence would prevail. The questions that continue regarding these very complicated situations cause great concern for parents trying to decide whether to immunize a child.

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