Ativan and getting punched in the face

Nurses General Nursing

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Hi all!

Situation. So I'm a new nurse, just out of school. My background is psych but I figured I'd give the ER a try to get some medical experience. Anyhoo, I'm in the observation area and I've got a patient with a kidney stone and appendicitis and an annuerysm. He's got an extensive mental health history of violence as well as narcotic addiction. But I firmly believe he's hurting. He doesn't have much ordered, even for a regular person, and he's acting up, getting more and more agitatied. He's a big dude so I call the doc to get some Ativan on board before we have an incident. My patient has developmental issues also so talking to him will get us nowhere. The doctor says he doesn't want to write an order for anything to calm this guy down because he said it's "not therapuetic" and we need to use other ways before resorting to drugs. I was basically just told to order security if things start getting bad. Now I've been in mental health and people getting hurt when someone goes off the chain isn't therapuetic either. But maybe I'm new. Is this response from a doctor out of the ordinary?

Specializes in Psych ICU, addictions.
Why was he getting more agitated? I'd be agitated too, if I had a kidney stone and appendicitis and wasn't getting appropriate analgesia. It sounds like this patient needed some pain medication, not a benzo. Treat the source of the agitation (pain), and you'll treat the agitation.

Also, giving a benzodiazepine in the ER when the patient is still being evaluated and diagnosed can be tricky, as you may end up masking symptoms. For example, a mental status change may brushed off as a side effect of the ativan when in fact it's a result of a stroke.

Plus the fact that for a small percentage of patients, Ativan is actually activating instead of sedating. So instead of calming your big guy down, it could have the opposite effect. If you're really looking to slow them down, Haldol/Benadryl or Zyprexa would be better (honestly, I'm a Thorazine fan but ED docs aren't comfortable with ordering that).

You'd do far better to assess and treat the underlying issue (i.e., the pain that kidney stone is causing him) before snowing him. Who cares if he has a narcotic addiction problem? Relieve the pain. Your goal in the ED is to stabilize his condition and relieve the pain, not start him down the road to detox and recovery. Especially if he's not ready and willing for it.

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The patient's pain was not being sufficiently addressed. You, the nurse, are the patient's advocate. It is your responsibility to advocate for the patient's needs, and if the physician is not responding appropriately to your concerns to use the chain of command to obtain appropriate medical care for the patient. A kidney stone is a very painful condition without the pain of appendicitis in addition. You said you charted to CYA: I assume you truthfully charted your pain assessment and the patient's description of their pain and it's severity, and your intervention (following the orders as given and involving security if needed), or are you saying you charted something else? How did you chart the patient's response?

I'm curious how that would work under these specific circumstances. I'm imagining the OP neglecting her other patients, saddling up her unicorn, and riding straight over to Jesus, himself. Obviously, it wouldn't go like that ....but who would one turn to in an acute care situation like this one to report that their own judgement is superior to the ER doctor's?

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Specializes in ER.
I'm curious how that would work under these specific circumstances. I'm imagining the OP neglecting her other patients, saddling up her unicorn, and riding straight over to Jesus, himself. Obviously, it wouldn't go like that ....but who would one turn to in an acute care situation like this one to report that their own judgement is superior to the ER doctor's?

She would request the physician respond to bedside (and actually see the patient), then repeatedly reassess and report her findings that the patient is in distress, that the 1mg morphine isn't enough, how about 1mg q5min until pain controlled? Bring in a more senior nurse to confirm the assessment. Document the requests to see/medicate and the physician's responses religiously. Bring the charge nurse into the conversation, and then the nursing supervisor, and each of those people will talk to the doc about their concerns for the safety of the patient and the rest of the unit. A lot of docs will give in because nursing staff is politely stating the patient hasn't gotten the care he needs. Depending on time of day, bring in the director of the ER and the nurse manager. Call the risk manager, if safety is an issue.

Convincing the doc can be done, and has been done. Approach him individually, then gang up on him. He needs to come up with a reasonable plan, or explain his lack of treatment. Look for an opportunity to bring in a consultant, or to ask the other ER doc for their opinion...perhaps there is a personal issue affecting care. Keep working at it until the patient gets treated.

It's pretty labor intensive dealing with an irate combative patient, advocating for decent care will hopefully lessen the overall workload. As a bonus, you'll be covering your butt legally and morally.

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Is there a family member or someone the patient knows who can sit with him and try to help him be calm? He might be afraid in the unfamiliar environment. Throwing stuff around? I'd have called Security for that.

Honestly, I hope no one gets hurt. But doctors today are afraid to order adequate pain meds and maybe they have to learn the hard way. If you get hurt in the process, I'd bet you have a good lawsuit against all of the people who did not help you - especially the doctor.

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Specializes in Emergency, Trauma, Critical Care.

The doc is clearly an @sshat based on his medication dosages...

who orders 1 mg of morphine? I've had 2 mg....on LOL who weigh 80 lbs

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Specializes in Hospice.

Not an ED or even really acute surg nurse, here, but "kidney stones, appendicitis and an aneurism" sound like part of the differential dx of acute onset severe abdominal pain.

I agree that better pain control is in order and needs to move up on the list of priorities. Maybe ED folks can talk more about where it fits in the process of diagnosing such potentially dangerous possibilities. My own teaching on the subject is waaaay outdated.

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Specializes in Adult Internal Medicine.

Few questions:

1. I assume this patient had a CT scan which showed these three things?

2. What did the patient come to the ED complaining of?

3. Had the patient been to that ED before? What's his history?

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Few questions:

1. I assume this patient had a CT scan which showed these three things?

2. What did the patient come to the ED complaining of?

3. Had the patient been to that ED before? What's his history?

And once youve addressed these questions then take the info

and ask again for pain medications... ER is tricky and patients are sometimes

very skilled

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Specializes in Hospice.
And once youve addressed these questions then take the info

and ask again for pain medications... ER is tricky and patients are sometimes

very skilled

Very true ... and sometimes that very skilled addict is also seriously ill.

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