What is your ED policy in these circumstances - page 2

by JessicRN

I have a few questions that I am looking to see what your ED hospital policy states or what you think 1) If you have a non trauma patient in your ED (Ie a pt who is septic or who overdosed or is in cardiogenic shock) who... Read More


  1. 0
    Quote from JessicRN
    Thanks we have a whole slew of new attendings who are straight out of residency and they are driving us nuts. One actually let a pt who overdosed have a BP <65 systolic for over 4 hours because they were too busy to put in a central line (duh) he was allowed to have dopamine only even though it only kept the BP at 60 systolic
    When I try to question her she say if I have a problem with her management of patients then I should take it up with the site director. I told her I will do just that but right now I want to save what was left of the Patients lungs and kidneys. I asked to add peep since the Patient was on a respirator and again I was turned down. I informed her since his BP was so low the likely hold of ARDS is great now and PEEP could help but again she turned me down. (by the way the pt went into ARDS and died he never came off the Respirator and he had ARF anything happen to the Doctor? NOPE) This was not my patient so I did not step in sooner I wish I had. The worst part is I stepped in when they had the central line in and started the Levophed at 1mg and kept the Dopamine at 10mcg/kg/min I bumped up both and had a BP of 105/60 in 15 minutes. This doctor I hope won't question me so much I know she is humbled. Not sure if there will be a lawsuit yet, I sure there would be if someone read his chart. The nurse involved it was her first day off orientation and she never worked ED before but someone said she had ICU experience (you are kidding )
    She actually tried to do it again on another patient the same day who became septic and tanked, that was my patient and I informed her I am the patients nurse and it is my goal to stabalize this pt as fast as I can so she can live not wait for a central line. I will take responsibility for my own patient I will start periperally and as soon as she gets the central line and comfirms it then and only then will I switch it out. (if took 1 hour to get a central line because she had to do the conscious sedation on the kid with the paronnychia) I informed her if she does not like this than she is welcome to take it up with my unit manager if she wished but my policy says central line preffered only and since she had no BP the RAC wins. ( she did not I think as I heard nothing).

    This same Doctor ordered the conscious sedation and became upset when every nurse said it was crazy (by the way she prerformed the conscious sedation but found no infection when she I&D'd the toe it also took multiple tries to get an IV and the child screamed for 30 minutes prior to the sedation. Pediatrics you don't usually do anything for a paranychia except foot soaks and and maybe ABx
    Paronychia. Yes, soaks, local treatment, right? And since when does paronychia come before kidneys and airways??? Was this child septic or just in pain or what? How did the child get triaged to the head of the line?

    Where is that doctor's supervisor? Chief of Service? Somebody who can correct her immediately, not let her kill people? The hell with her humbling, there are lives to save! Maybe a very gentle hint would be in order to the dead person's survivors that a lawyer needs to be consulted. This doctor is incompetent and needs a serious comeuppance, since she will not listen to good advice or consult her superiors. Was Resp Therapist around to advise her on PEEP?

    Also, not to upset or hurt you, but if you knew that nurse was fresh out of O, you should have intervened, even if the patient was not yours, I think. There's stepping on toes and there's saving of lives. I dont know the whole story and am open to being corrected. Sorry to be critical but I am really appalled that this doc's timidity, inexperience, and arrogance, plus your not stepping in and involving your boss and the doc's boss seem to have caused an unnecessary death.
    Last edit by Vito Andolini on Jan 30, '09
  2. 0
    1) If you have a non trauma patient in your ED (Ie a pt who is septic or who overdosed or is in cardiogenic shock) who needs stat dopamine and levophed vasopressors and has at least one good peripheral line do you not start vasopressors peripherally but wait to start a central line (not EJ) or do you start the vasopressors first then when the patient blood pressiure is stablized place a central line.

    Start fluids and then pressors while getting the central line. Since it is good practice to be sure your patient is not volume depleted before using pressors there is often a few minutes of time to get the central line anyway. Policy says central line but no one dies while we are getting a central line if we can help it.

    2) How often does your doctors immediately revert to concious sedation for healthy toddlers who need minor procedures ie exploring a toe paronnychia without trying less drastic methods first ie digit block. sedation for CT does not count.

    Never

    3) Do you still follow conscious sedation policy when you only use a tiny amount versed (1mg for a locked jaw or CT )

    Historically Versed is one of the main sedative agents that conscious sedation policies were created for. If I am attempting to sedate the patient only a little it still counts. Following the policy protects your back. I also use Versed for other reasons so I don't always use the policy. If the patient becomes sedated with any medication even if you were not intending it following the policy is a good idea.

    4) Do you use propofol for conscious sedation in the ED for shoulder and hip dislocation. If so who gives it?

    Love the stuff. I would call it deep sedation for these types of procedures. The patient's muscles need to relaxed enough to reduce these dislocations. 2 ED MDs must be present and one must give it, one monitor the patient. Anesthesia can also give it. We also keep RT at the patient's airway.
    Last edit by Footballnut on Jan 31, '09 : Reason: spelling
  3. 0
    Nope the CEO let go the director and hired a whole new group of Doctors all friends of the new director. Used to be even though we had useless Interns doing care at least we had good PA's to pick up the slack but the ED director also hired all new grad PA's There are only 3 of the old MD's left the rest are brand new. This is one of his pets. We they came in we stepped back 20 years in respect for nurses. It is really sad.
    The director does not like me much because I stand my ground and when he feels the need to yell at me or someone else I stand up and say "your behavoir is totally unacceptable if you wish to talk to me talk to me with respect'. (he usually walks away and refuses to talk to me for days that included patient care he just writes the order and puts it in the rack and hopes I find it). Oh by the way the nursing chain of command has also changed all the way from the director down and none of the nursing brass ever worked in an ED before and none have degrees which was a prerequisite for the position. We had a hiring commitee who turned down all the current brass because of their lack of experience and education. They are no help because they worked with the medical ED director
    Here is the new system which has changed 7 times in 1 year: We no longer have rapid assessment we have 2 RN's and one PA to assess all patients those who are 4and 5 stay in the 5 Rapid assessment rooms the pediatrics go to the pedi area no matter who sick or well and the rest go to the main. NO ONE WAITS IN THE LOBBY if there is an empty bed in the main and there is a pt with a sore throat he goes there if it is a pedi with a sore throat and there are no pedi beds then the ped goes to the main.If a patient wines really loud they get to the head of the pack. and come to the main without even being triaged.
    Yes we cater to the winy and the ones who use us as a clinic. The sick ones they get short changed.
  4. 0
    We start the dopa/levo if patient is critical and request the central line. Chances are if you don't, you won't have a line for long and a mess on your hands.

    Conscious sedation is conscious sedation..... it's the drug and not the dose. If they are calling it a "fugue state' they are just trying to get out of a consent.

    Pedi sedation, depending on what is given (IM Ketamine etc...) we give it (the doc does). It's a risk/benefits issue. There is not reversal agent for Ketamine and you give supportive measures (bag 'em... etc....).

    We do give propafol in the ED "procedural"... it is not deep sedation/used to induce general anesthesia. Once again, it is our docs who give it as they must give the bolus and the nurses only the drips.

    Hope this Helps!
  5. 0
    Quote from jessicrn
    i have a few questions that i am looking to see what your ed hospital policy states or what you think

    1) if you have a non trauma patient in your ed (ie a pt who is septic or who overdosed or is in cardiogenic shock) who needs stat dopamine and levophed vasopressors and has at least one good peripheral line do you not start vasopressors peripherally but wait to start a central line (not ej) or do you start the vasopressors first then when the patient blood pressiure is stablized place a central line.
    the first er i worked had an unwritten rule: dopamine over 5mcgs needed a central line. 5mcg was ok in a large bore piv. realisically, if the patient is crumping and needs dopamine, we're not going to withhold pressors while we wait for a central line.

    2) how often does your doctors immediately revert to concious sedation for healthy toddlers who need minor procedures ie exploring a toe paronnychia without trying less drastic methods first ie digit block. sedation for ct does not count.
    i think most of ours tried to do less invasive procedures first. we were lucky at the first er b/c we had child life, and a lot of times they were able to provide enough distraction. that or else we tied them to the papoose board and did it quick!

    3) do you still follow conscious sedation policy when you only use a tiny amount versed (1mg for a locked jaw or ct )
    if it's only versed, no. when you get two drugs together (in a close amount of time at least) we would consider is sedation.

    4) do you use propofol for conscious sedation in the ed for shoulder and hip dislocation. if so who gives it?
    1st er- yes. loved it, nurses gave it.
    2nd er- no. crna's would come down and give it, and i think i can remember it being given once.
  6. 0
    Dont ever with hold a needed medication while waiting for a central line! Whats going to harm the pt first? As nurses our motto: Do no harm, would be a complet controdiction. As soon as you pop the versed and mix with narcotics its considered conciouse sedation, ive never used propofol for hips or shoulders, my facility uses versed and fentanyl (its an ortho favorite).


Top