I had a patient with critical AS. I forget how small her valve surface area was, but it was very small. She often would develop chest pain from just transferring to the commode and back to bed. Despite her AS, she had perfect healthy coronary arteries. This woman was 87 years old. Surgical intervention was not a possibility for her, given her age, severe deconditioning from lack of mobility, her uncontrolled diabetes and weight issues. The plan was valvuloplasty once her sugars were stabilized and all work up was compete. In regards to her chest pain, it typically resolved with rest and O2. She said she always got chest pain and pressure when mobilizing at home. One day in particular her chest pain was quite bad. Her BP was 175/90 (that's her norm and drs wanted SBP <180), sats were 92%, she reported the pain to be 7/10 (usually it is 4/10 for her) and she had some SOB. I put her on 4L O2 and decided to give 2mg IV of morphine instead of Nitro spray which was also on the MAR. I rechecked her BP (now it was 170/87), sats 94% and pain slightly improving to 6/10. She still looked uncomfortable, but her SOB was gone. I asked a RN to stay with her while I called the cardiologist to let him know her pain started while at rest and was treated with morphine 2mg IV and O2. He asked me why I didn't give Nitro. I said I didn't feel comfortable giving nitro spray because her AS was critical and felt that morphine was the safer choice. He said I should have treated her chest pain as I would any cardiac patient presenting with angina (3 sprays nitro, then onto morphine). I was like, "Are you serious?" He actually discontinued the morphine and kept the nitro spray order. Respectfully, I questioned his rational and he said even if the nitro spray would relax that valve, it wouldn't be that drastic and her BP would hardly be affected. I was doubtful and expressed my concern. He said to give it and if her SBP drops to less than 160 then to call him.
I checked on my patient and her pain was 5/10 now, no SOB, BP 174/88 sats 94%. I was so upset I couldn't give the morphine because I knew nitro was not the right call. I called the charge nurse and she was surprised at the nitro order too and said to call the interventional cardiologist (the Dr who was going to do the valvuloplasty) for a second opinion. I did, and he adamantly agreed that nitro was NOT the right call and to reorder the morphine and give it and that he will call the cardiologist. I treat my patient with morphine and she is now more comfortable, she BP stable. Ten minutes later the cardiologist walks on my unit and rewrites the morphine order and discontinues the nitro.
Has this ever happened to you? I am so glad I trusted my instincts!