Really, Doctor?!

  1. So I had my first code called on my my patient last night. Without going into a lot of details, a strike code was called but basically the patient had too much pain medication (she was on Q2H dilaudid).

    Her doctor previously rounded before shift change, saw she was very lethargic & had pin-point pupils. Didn't order anything but changed a few other things.

    When shift change came we did bedside report & she was acting different from her usual self so a code was called. When I called the doctor he was upset that the shift coordinator wanted to transfer her to the ICU & ordered Narcan.

    *I* was pissed because HE saw her & could've order Narcan when he SAW her! I saw the doctor today & he said not to call a code. It took all of me not to say anything back at him.

    The patient wasn't transferred, the Narcan helped her & she is fine today.
  2. Visit OrganizedChaos profile page

    About OrganizedChaos, LVN

    Joined: Aug '13; Posts: 7,942; Likes: 20,115

    42 Comments

  3. by   Been there,done that
    The patient did not need to be in ICU to complete the opioid reversal.
    Both the doctor and the nurse are responsible to take action.
    If you noted the patient had pin-point pupils and lethargy, you should have sought the Narcan order at that time.
  4. by   KatieMI
    It is a common misconception among nurses that when provider "doesn't order anything" then he or she is lazy, doesn't know what to do, doesn't care, etc.

    In fact, at least half of what providers are called for are either variants of norm (yeah, pressure 90/50, when patient never was over 105/60), common side effects or basic stuff which should be covered by standing protocols.

    And, yeah, pushing Narcan should be standing order for every patient on any dose of opioid. And, unless he's so deep that tube has to go down, it requires neither code, nor ICU.
  5. by   OrganizedChaos
    When did bedside report her speech was slurred, confusion & L sided weakness. That was not her norm. I didn't call the code & the shift coordinator decided to continue with it & with the transfer.

    I'd rather be safe than sorry. There was no Narcan order until I called the doctor.

    The thing I don't get is that if she got THAT worse between his visit & shift change (it wasn't long), why didn't he do anything when HE saw her?

    I will continue to call codes if there is a dramatic change in my patient's condition, I'm not going to call the doctor. He must be nuts!!!! Damned if you, damned if you don't.
  6. by   Here.I.Stand
    Quote from OrganizedChaos
    When did bedside report her speech was slurred, confusion & L sided weakness
    Yeah that warranted a stroke code. Time is brain and better to err on the side of caution
  7. by   OrganizedChaos
    Quote from Here.I.Stand
    Yeah that warranted a stroke code. Time is brain and better to err on the side of caution
    I just didn't want to give out too much info. Lol. Oh well! Yeah, I felt it did too. Apparently the doctor didn't believe so. Then to have the doctor tell me to NOT call a code?! Excuse me?! Hell no! ESPECIALLY after he JUST laid eyes on her and did NOTHING!!!! That was MY patient and that is MY license. If he likes to dangle his license over the edge like that, cool beans. I don't. I hope he has good insurance. Because if *I* found out he rounded on MY family member & did nothing, I would be none too pleased.
  8. by   NuGuyNurse2b
    At my facility if you're getting something like Dilaudid Q2 you might as well get a PCA pump; ain't nobody got time for that. Regardless, either of those orders would come with prn Narcan for obvious reasons, as well. It's an actual "bundle" in the order entry system when the md selects it.
  9. by   KatieMI
    Quote from OrganizedChaos
    I just didn't want to give out too much info. Lol. Oh well! Yeah, I felt it did too. Apparently the doctor didn't believe so. Then to have the doctor tell me to NOT call a code?! Excuse me?! Hell no! ESPECIALLY after he JUST laid eyes on her and did NOTHING!!!! That was MY patient and that is MY license. If he likes to dangle his license over the edge like that, cool beans. I don't. I hope he has good insurance. Because if *I* found out he rounded on MY family member & did nothing, I would be none too pleased.
    Really, OrganizedChaos,

    1). you've got to chill down. Seriously.
    2). you've got to stop getting into that psychology of patient's ownership. It doesn't help anyone. You're all working together, whether you like it or not.
    3). as your facility doesn't seem to have it, you have to make your own "patient's checklist" and use them. Everyone on any dose of opioids => standing order for Narcan. Everyone with DM => standing order for IV dextrose. Everyone on tele without renal failure => replacement protocols for lytes, etc. Correct as needed according to your local policies and what your RNs are doing. If checklist is not complete, ask for orders as soon as possible. It will save a lot of nerves and trouble for everyone.
    4) and the main in the situation described: only one part of neuro assessment which is legible for a patient on high or escalating dose of opioids is respiratory drive (basically, RR plus air entry), which can define "code blue" (acute CPR) but not stroke code. Everything else, including complete neuro exam, must be done after Narcan. It takes only 2 to 5 min to work in full. "Time is brain" is said about a person who suddenly fell in shopping mall and cannot speak, not about someone on dilaudid Q2 IV.

    The Q2h frequency is borderline for IV hydromorphone as its T1/2c is 2.3 h under ideal condition. It means that if it is given strictly every 2 hours, every next dose "catches the tail" of action of the previous one. Early or later, it inevitably leads to building up and overdose even in a person with perfectly functional liver and kidneys. Literally everything that might go wrong with human body makes this effect worse.

    https://www.accessdata.fda.gov/drugs...034s018lbl.pdf

    5). You are a nurse (yeah, I remember you're LPN but you're still a nurse), and you went through school and were given autonomy for a reason. Your job is not to "get doctor to do something". Your job is to access (repeat as needed) and think (repeat as needed as well) and become a nurse whom providers trust as themselves. A nurse about whom they know - if she calls, drop everything and get there.

    Sorry if that is not what you would like to hear but I have experience of being on both sides of the line.
  10. by   Palliative Care, DNP
    Every patient that I order opioids for also has a Narcan order placed. Unless, they are comfort transitioning to hospice.
  11. by   OrganizedChaos
    Quote from NuGuyNurse2b
    At my facility if you're getting something like Dilaudid Q2 you might as well get a PCA pump; ain't nobody got time for that. Regardless, either of those orders would come with prn Narcan for obvious reasons, as well. It's an actual "bundle" in the order entry system when the md selects it.
    I have no idea why she didn't have Narcan on her list. I have taken care of other patients with opioids & sometimes they do have Narcan, sometimes they don't.
  12. by   OrganizedChaos
    Quote from KatieMI
    Really, OrganizedChaos,

    1). you've got to chill down. Seriously.
    2). you've got to stop getting into that psychology of patient's ownership. It doesn't help anyone. You're all working together, whether you like it or not.
    3). as your facility doesn't seem to have it, you have to make your own "patient's checklist" and use them. Everyone on any dose of opioids => standing order for Narcan. Everyone with DM => standing order for IV dextrose. Everyone on tele without renal failure => replacement protocols for lytes, etc. Correct as needed according to your local policies and what your RNs are doing. If checklist is not complete, ask for orders as soon as possible. It will save a lot of nerves and trouble for everyone.
    4) and the main in the situation described: only one part of neuro assessment which is legible for a patient on high or escalating dose of opioids is respiratory drive (basically, RR plus air entry), which can define "code blue" (acute CPR) but not stroke code. Everything else, including complete neuro exam, must be done after Narcan. It takes only 2 to 5 min to work in full. "Time is brain" is said about a person who suddenly fell in shopping mall and cannot speak, not about someone on dilaudid Q2 IV.

    The Q2h frequency is borderline for IV hydromorphone as its T1/2c is 2.3 h under ideal condition. It means that if it is given strictly every 2 hours, every next dose "catches the tail" of action of the previous one. Early or later, it inevitably leads to building up and overdose even in a person with perfectly functional liver and kidneys. Literally everything that might go wrong with human body makes this effect worse.

    https://www.accessdata.fda.gov/drugs...034s018lbl.pdf

    5). You are a nurse (yeah, I remember you're LPN but you're still a nurse), and you went through school and were given autonomy for a reason. Your job is not to "get doctor to do something". Your job is to access (repeat as needed) and think (repeat as needed as well) and become a nurse whom providers trust as themselves. A nurse about whom they know - if she calls, drop everything and get there.

    Sorry if that is not what you would like to hear but I have experience of being on both sides of the line.
    1) Chill down about what?
    2) I don't understand what you're saying here.
    3) Yes, that is a good point. Thank you.
    4) I was not the one who called the stroke code, it was the night shift nurse. I thought it would've been more appropriate to call a code white since it was a change in status.
    5) I just don't understand why the doctor was upset why we called a code (regardless of what it was) when he had just saw her & saw her condition. I'm going to protect the patient & do what is best for them. It was at shift change & even during the day it's not easy to get ahold of a doctor. Why would I call the patient's doctor when there is a HUGE change that could be life altering?
  13. by   OrganizedChaos
    Quote from Palliative Care, DNP
    Every patient that I order opioids for also has a Narcan order placed. Unless, they are comfort transitioning to hospice.
    I have noticed that some patients do & some don't. I'm guessing it depends on the doctor. You would think it would be an automatic add on.
  14. by   AnnieOaklyRN
    It sounds like this patient was semi alert? If she had adequate respiratory effort and was able to protect her own airway, just give the narcotics time to wear off, and skip the transfer and the Narcan!

    Annie

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