Verbal order-Denied by resident

[Traumamama02]

Wednesday morning I came into work and took report on a patient in airborne isolation r/o TB, a laundry list of co-morbidities, mild respiratory distress, vitals not to bad in the moment but I'm sure you can see where this is going.... yup straight to RSI hell with a chaotic attending and a hot shot resident.

Long story short, as the RT was preparing her equipment, I was preparing mine, setting my monitor parameters, etc, etc. The resident walks in to the room with a spiked and primed bottle of propofol and clearly says 'here ya go, it's already for you', and hangs it on an IV pole. I clarify the starting dose with him and he gives me a verbal order for 30 µg/kg/min. Attending walks in the room. Then I clarify what RSI drugs he wants; 20mg Etomidate and 120mg of succ.

Fast forward, the patient is intubated, Sp02 is crap, abg is crap, blood pressure has been crap prior to me assuming care but the current trend for 2 hours has been adequate with resuscitation efforts, pt is waking up within seconds post securing the tube, RT is suctioning and simultaneously, I pipe up and start a conversation about starting the propofol at a lower dose than the resident had ordered and adding an analgesic, fentanyl, to accommodate propofol (which as we all know propofol has hypotensive side effects and no analgesic properties). My rationale being that I can keep the prop at a fairly low rate, keep the blood pressure adequate and the patient can be more comfortable and less likely to wake up with PTSD.

Attending shuts my idea down and states that propofol has analgesic properties and she'd rather use Versed and fentanyl bc versed does not have a profound effect on blood pressure as propofol... lol...wait it gets better...so keep in mind that now is not the time to educate a physician and what not because the patient is fighting the vent and circling the drain respiratory wise and I've got to move this patient out of isolation and into the Critical Care area of the ER; according to infectious disease it's OK to do that because now the patient is a 'closed circuit' ... I know I know ... ***, right.

Back to RT suctioning... The attending requests her to stop suctioning so we can cycle blood pressure and get an accurate reading before we start the propofol bc this man needs sedation now and we need him calm and I have the propofol hanging in front of me, and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy and have them validate it so I can get it out and blah blah blah...

So the nurse I give bedside report (who should be helping me bc she has no pts) to can bridge the gtt to the new sedation orders. in my mind this keeps the patient safe and the tube is less likely to come out, exposing the dept, plus I have 3 other neglected patients ...I need to hand off this one and now ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate blood pressure to start the propofol, so I start the propofol at 10 mcg/kg/min instead of 30; I followed pharm protocol bc frankly 30 is to much to start with this guy...anyway I titrate by 5mcg q 5 to 20mcg and everyone is ready in the assigned area, patients is chill, last bp is 110/70-ish and we go, fentanyl is overridable in the pyxis, versed is not ..let's get that fent going ... and hand off is complete.

Now I'm charting and the charge tell me to save it and come talk to him now.. I comply, the director is there waiting .. the conversation starts with, 'did you hang propofol without an order?' 2 docs say you did and there are writing you up bc the pt decompensated and is now on 5 mcg of levophed, (5 people!!!)and the prop is still hanging and now at 40!!! Resident dictates he never gave any orders for propofol... when I asked the nurse that took over for me how long it took her to bridge him off the propofol, she said she didn't because propofol is used so often that she didn't bother looking at the orders and just continued to use it...

Resident is lying!!!! And I'm blown away at all of it!!!

Bring on the question and comments please!!!

[Insperation]

Who's the nurse who actually pulled the med from the pixus? I don't work in critical care but I would NEVER pull a narc for someone else, without myself actually administering. I guess that happens a lot in the ER? It still sounds pretty sketchy.

Sounds like the ER resident wanted to give it but knew his attending might not approve. Therefore he manipulated another nurse into pulling it, then gave a verbal order and didn't put it in the chart. Lammmeeee.

[Guest374845]

Who's the nurse who actually pulled the med from the pixus? I don't work in critical care but I would NEVER pull a narc for someone else, without myself actually administering. I guess that happens a lot in the ER? It still sounds pretty sketchy.

None of your skepticism surprises me given your half year of nursing experience, all of it med/surg. Yes, verbal orders are a significant amount of orders received in the ED, and the absolute majority in critical situations where literally every doctor or nurse has their hands tied up on/in the patient. There's nothing sketchy about a runner nurse or pharmacist pulling meds from the pyxis, as verbals are flung around, in order to bring them to the bedside.

But... this thread highlights the rare-ish risk associated with that practice.

[Insperation]

oh well ok. Yah I've never worked in the ER.

And I have 1 year of med surg experience now...thank you very much :) I need to update my thing

Even I work in the ER, I'm going to be very skeptical about pulling narcs under my name and just "throwing them around" based on verbal orders. But hey if you say it happens then I guess I believe you. I have no reason not to.

It makes sense to me...you gotta do what you gotta do. Maybe I'm skeptical cus med surg is so protocol and rule based.. I'd much rather be in the ER actually.

[Ruby Vee, BSN]

Who's the nurse who actually pulled the med from the pixus? I don't work in critical care but I would NEVER pull a narc for someone else, without myself actually administering. I guess that happens a lot in the ER? It still sounds pretty sketchy.

Sounds like the ER resident wanted to give it but knew his attending might not approve. Therefore he manipulated another nurse into pulling it, then gave a verbal order and didn't put it in the chart. Lammmeeee.

As you become more experienced, or work in more acute areas, you will find yourself pulling meds to be administered by another nurse, or begging another nurse to "pull some Ativan for me, please on this dude here in 538. And ask the CNA to bring me some restraints." In fact, you may find yourself drawn to the sound of an agitated patient hollering and ask his nurse "What drug do you want me to pull?" When the staff starts to gather for a code situation, SOMEONE has to fetch meds to be given by whomever is closest to the IV access and has a free hand -- be that RN, NP or MD. Or even, in rare cases, that medical student who used to be the night nursing supervisor.

[jdub6]

Even I work in the ER, I'm going to be very skeptical about pulling narcs under my name and just "throwing them around" based on verbal orders. But hey if you say it happens then I guess I believe you. I have no reason not to.

This may be petty but propofol is not a "narc." It is not on a DEA schedule. It is a legend drug. I have never worked in a facility where "every drop must be accounted for" i.e. I've never had to waste with a witness and actually have never gotten flack for not recording waste at all. It is documented that propofol is diverted and abused and i imagine that if a facility had a problem they might track it more carefully...

i've never had a provider ask me to pull propofol and give it to them; i pull other legend drugs (things like lidocaine for suturing or epi for hemmorhoid injection) and give them to providers all the time without a thought-i document in the chart "lidocaine given to dr dre for administration for suturing, procedure in progress now." in my state propofol is considered an anesthetic and when pushed must be given by a LIP except in critical care areas for intubated patients who can recieve it from a trained RN under certain conditions. i have never been in this position since i work in critical care but if i were asked by a doc to pull propofol for them to give a patient i wouldn't have a problem doing it-i would document that it was pulled and given to them to administer. an actual narcotic like morphine i would not let out of my sight until in the patient or appropriately wasted. i could imagine that the "puller" in this case had a similar train of thought (since the patient wasn't intubated yet when the drug was pulled its possible that in the OPs state a LIP must give to non-intubated patients and the nurse saw nothing strange about the request.

Finally, in critical areas as well as critical situations elsewhere it is common for med students and 1st year residents to be present gawking-ahem i mean learning-but not taking an active role. At times the spectators are sent to gather supplies or meds-while they wouldn't be giving orders in that case the nurse who pulled the med didn't know all the circumstances. I wouldn't find anything odd with a resident rushing out of a critical situation-and intubating a combative patient qualifies-asking whoever is in sight to pull a non-controlled drug. i would pull it and hand it to them. Again a controlled drug i would be more careful.

I strongly recommend becoming familiar with the DEA classification of drugs you are handling-it will help you make sure your butt is covered and save you from unnecessary headaches tracking a med you don't have to. (for example many nurses think benzos are schedule 2 like opiates-they're actually schedule 4 which doesn't really effect handling in acute care but does have very different rules for outpatients.

suboxone is schedule 3.) Obviously if your facility has stricter policies about certain drugs its important to know that too but unless you plan to stay where you are forever it will serve you well to understand whether you're witnessing wastes to satisfy DEA rules, facility policy or both. it will also keep you from refusing to facilitate administration of something like propofol in a critical situation because you erroneously believe it is a scheduled narcotic.

[Insperation]

its not petty, it's good to know. I retract my skepticism regarding pulling propofol lol..probably shoulda just been a bystander on this topic :)

[campesina]

If the attending at told me to use Fentanyl and Versed as sedation, I would've not started the propofol at all and just would've started the other two drugs. The resident was a jerk for denying what he did and said, but I think it was still incorrect to have even started the prop AFTER the attending had stated that she wanted different drugs used. I think that's where you got yourself into trouble.