HR in 40s. Doc insisting on dig IV

[General E. Speaking, RN, RN]

One of the nurses on my unit had a pt (due to be discharged) but had a short run of SVT. We called the cardiologist to update. At the time the HR was in the 70s. He ordered dig 0.25mg IV X 3 doses Q4hrs apart.

After the first dose, the HR dropped to and stayed in the low 50s occasionally dropping to the hi 40s. No more dysrhythmias noted. She came to me and told me that she wasn't going to give the second dose. I agreed but told her to call the doc just to update.

He became very irritated (new doc to us) and kept insisting that she give the doses as prescribed. She even ask him what if the HR drops to the 30s by the time the last dose is due? What then? He told her I SAID TO GIVE ALL THE DOSES OF DIG.

I wish I had been the one to call him. I would have loved to tell him, "No sir, I will not give that dose. The HR is too low. I am calling you to update you on the patient's condition. Thank you." And hung up (gently...not rudely:D)

We didn't give the doses and HR stayed in 40-50s all night. I was in a meeting when that doctor came to round. It will be interesting to see what kinds of interactions we are going to have in the future with this cardiologist. If crap like this continues, we will have to have a little chat.

[chenoaspirit, ASN, RN]

all I can say is "wow"

[netglow, ASN, RN]

What the heck is it with cards?!?!

Wonder what he (she?) would've said if you asked for parameters. HAAAAAAAAAAAAAAA! Not gonna happen. Sometimes I think they are all walking around with their undies in a bunch. I wonder if it's best to ask once, then document, then go up the chain so as not to waste your brain cells on some of them. :anbd:

[dcarriv]

i agree with you, it should not have been given. one thing you could have done was tell him or her to give it themselves, although i would not have let them do that either. i wonder what it is with card too. where i work we have had people sit in 3rd degree block on a friday sit with external pacing until monday with minimal sedation and pain meds. we have had someone die from sitting this long, but nothing was done about it.

[Otessa, BSN, RN]

One of the nurses on my unit had a pt (due to be discharged) but had a short run of SVT. We called the cardiologist to update. At the time the HR was in the 70s. He ordered dig 0.25mg IV X 3 doses Q4hrs apart.

After the first dose, the HR dropped to and stayed in the low 50s occasionally dropping to the hi 40s. No more dysrhythmias noted. She came to me and told me that she wasn't going to give the second dose. I agreed but told her to call the doc just to update.

He became very irritated (new doc to us) and kept insisting that she give the doses as prescribed. She even ask him what if the HR drops to the 30s by the time the last dose is due? What then? He told her I SAID TO GIVE ALL THE DOSES OF DIG.

I wish I had been the one to call him. I would have loved to tell him, "No sir, I will not give that dose. The HR is too low. I am calling you to update you on the patient's condition. Thank you." And hung up (gently...not rudely:D)

We didn't give the doses and HR stayed in 40-50s all night. I was in a meeting when that doctor came to round. It will be interesting to see what kinds of interactions we are going to have in the future with this cardiologist. If crap like this continues, we will have to have a little chat.

All i can say is WOW-I'm with both of you, nursing judgement in this matter.

otessa

[clemmm78, RN]

Hopefully your actions were well documented. I ticked off a dr royally for something similar and I documented it. I didn't give the medication (a dose 10 x the usual of a sedative) and the psych yelled at me over the phone that he was the dr and I wasn't. I called the nursing supervisor to tell her that I was refusing to give the medication, explaining that when the dr gave me the order (over the phone), I voiced my objection. She backed me up 100%.

Anyway, when I was talking to the dr, I told him if he wanted the patient to have that much of the medication, he was more than welcome to come and give it himself. You know what? He *did*!. But my nsg supervisor still backed me up, saying that the dose was too far out of our comfort level to give without adequate back up.

The patient was fine in the long run, but what if I had given it and he wasn't fine? The dr wouldn't have been in trouble, that's for sure.

[wtbcrna, MSN, DNP, CRNA]

Not to cause an argument, but if the patient's BP was stable I would have informed the cardiologist of the HR and still given the second dose. A lot of times patients will have an exaggerated response initially to a med and then level off quickly. I understand your concerns, but now that I am a provider I often feel frustrated when I give an order and the nurses are reluctant to follow it. I at least have the courtesy to explain my position and reasoning behind my orders when there is a disagreement unlike your cardiologist.

[wtbcrna, MSN, DNP, CRNA]

Hopefully your actions were well documented. I ticked off a dr royally for something similar and I documented it. I didn't give the medication (a dose 10 x the usual of a sedative) and the psych yelled at me over the phone that he was the dr and I wasn't. I called the nursing supervisor to tell her that I was refusing to give the medication, explaining that when the dr gave me the order (over the phone), I voiced my objection. She backed me up 100%.

Anyway, when I was talking to the dr, I told him if he wanted the patient to have that much of the medication, he was more than welcome to come and give it himself. You know what? He *did*!. But my nsg supervisor still backed me up, saying that the dose was too far out of our comfort level to give without adequate back up.

The patient was fine in the long run, but what if I had given it and he wasn't fine? The dr wouldn't have been in trouble, that's for sure.

Medication doses are not cut and dry if the patient was used to getting that much medication normally then that dosage could have been just fine for that particular patient. Communication goes a long way when your a provider, and yelling rarely helps.

I gave a patient complaining of pain the other night 5mg of Versed, 100mg of Ketamine, and 8mg of Dilaudid over 30mins. This was on top of 8+mg of Ativan, oxycodone, oxycontin, morphine PCA, methadone, and lyrica he was already on. His pain seemed to ease a little, but he was still wide awake c/o pain. It is still amazes what levels of medication patients can get used to.

[deenasao]

wtbcrna, The risks outweigh the benefits in this case, in my opinion. If the hr started to rise the dig could have been given. If it dropped you would have a real problem on your hands.

[wtbcrna, MSN, DNP, CRNA]

wtbcrna, The risks outweigh the benefits in this case, in my opinion. If the hr started to rise the dig could have been given. If it dropped you would have a real problem on your hands.

I understand your concerns, but I think the benefits outweigh the risks by giving the Digoxin. My mindset tends to be a little different these days as a provider though. I am comfortable treating low heart rates, and I know that having low heart rates (in general) tend to be much less problematic for a patient's heart than tachycardia. Theses kind of problems could often be avoided by better communication by the provider . The cardiologist owed you an explanation at the very least if they wanted to give a medication to be given outside of its normal parameters, because it is you not the cardiologist that is taking care of the patient and will have to deal with the problem if something occurs.

[healthstar, BSN, RN]

I thought you couldn't give Dig if the clients heart rate is below 60

[PostOpPrincess, BSN, RN]

Had you given it, his answer would have probably been, "well why would someone give that if the heart rate is in the 40's?"

Prudent nursing always wins out.

Thank you very much.