Intubation - confused about orders

Esme12, ASN, BSN, RN · Dec 12, 2014

Intubations are not peaceful if emergent.....I have always administered the anesthetic agent first to knock them out.

RNexplorer · Dec 12, 2014

Intubations are not peaceful if emergent.....I have always administered the anesthetic agent first to knock them out.

This wasn't emergent... Patient's ABG was almost normal... Patient was holding Spo2 at 95% on non-rebreather... Patient's RR was normal.

So you usually give them etomidate first, not roc? I don't understand why the order was for roc first?

Here.I.Stand, BSN, RN · Dec 13, 2014

If it happens again, I'd just say "First, how much etomidate are we giving?" The MD's mind could have been pulled in two directions at once, and ordering the roc first could have been an honest mistake on his part (we've all made them.) I can't think of a single reason to paralyze first, sedate second.

Here.I.Stand, BSN, RN · Dec 13, 2014

If it happens again, I'd just say "First, how much etomidate are we giving?" Or simply, "Let's give the sedative first so we don't traumatize him." The MD's mind could have been pulled in two directions at once, and ordering the roc first could have been an honest mistake on his part (we've all made them.) I can't think of a single reason to paralyze first, sedate second.

akulahawkRN, ADN, RN, EMT-P · Dec 13, 2014

This wasn't emergent... Patient's ABG was almost normal... Patient was holding Spo2 at 95% on non-rebreather... Patient's RR was normal.
So you usually give them etomidate first, not roc? I don't understand why the order was for roc first?

That's just the thing... while the ABG was almost normal, the fact that the patient required a non-rebreather mask to maintain the SpO2 of 95% means something is wrong. RR being "normal" is only one part of the puzzle. What was the respiratory effort? Was the patient's tidal volume sufficient? Was this patient tiring out? While this intubation probably wasn't emergent, it probably was very necessary that it be done fairly soon. I would further imagine that the room-air ABG would have been close to frightening.

I'm a new grad and have yet to find a job, but I find it quite odd that the MD asked for Roc first. There's a darned good reason why we normally sedate and then paralyze. While I'm certainly not new to intubating patients (quite rusty actually), I've never had RSI in my scope of practice. That doesn't mean that I'm not at least somewhat familiar with doing it.

If the "first, how much etomidate..." doesn't do the trick, you might want to get more direct if the doc is that distracted. Some thing along the lines of, "for my own knowledge, why are we paralyzing first instead of sedating?" There may be a very valid reason to do this, and if so, I want to know the rationale for it... and asking for the rationale may cause the doc to realize the error.

EMSnut45, BSN, RN, EMT-P · Dec 13, 2014

You are a pt advocate. It is perfectly acceptable for you to speak up in a professional manner. I have and will continue to do so for my pts. They are relying on us to do that!

After reading your reply though, my bigger question would be why are they intubating a pt who does not appear to be in a moderate to severe amount of distress (granted that SpO2 is not great on a NRB and they will most likely decompensate shortly, all other respiratory signs don't point to immediate impending respiratory failure). From my experience, a little non-invasive support does wonders and can prevent the pt from needing intubation. Without knowing more particulars, as an ICU Nurse, Critical Care Transport Nurse, and Paramedic, the laryngescope and ETT would not be the first trick I'd pull out of my bag.

I'm not sure how long you have been in the ICU, but experience will help you decide when and how to speak up. I love the doctors that I work with, but we are a TEAM caring for these pts. If one of us feels like there is a better/safer/more appropriate way, they need to speak up. I expect the same from my peers. When I function as a paramedic, my EMTs who function under me know they can and HAVE spoken up. Sometimes they see something I don't. Maybe I'm having a blonde moment. Or possibly it's an opportunity to do some teaching with them.

Hang in there!

MunoRN, RN · Dec 13, 2014

I'm not totally clear on why the patient is being intubated either, although there is supposedly a trend of going away from using non-invasive positive pressure ventilation (ie BiPAP) for rescue therapy and going back to quicker intubations, which I can't say I agree with.

In general the nurses at my facility and others I've worked at don't "allow" paralytics to in effect without some sort of sedation, preferably with an amnesic such as versed. If the Doc orders paralytics they are given options of what to give along with it, but I don't know of any nurses who would agree to give the paralytic without sedation. Same goes for patient's coming out of the OR, if they haven't been 'reversed' and are still significantly under the effect of the paralytic then they don't get the option of not writing for sedation until the paralytic lightens up (we write it on their behalf).

RNexplorer · Dec 13, 2014

Thanks for everyone's comments. I'm new to the ICU, and I discussed this with the charge nurse BEFORE even setting foot in the patient's room. I told her the medications I would expect to give first. However, she gave me direct orders: "you must follow exactly what the physician tells you to do," plain and simple. She was adamant. I was a little thrown off when the doc told me to push roc first... but I thought maybe he knew more about the onsets of action or something... I thought it was possible that I could be wrong, especially since the charge nurse was so adamant about me directly following the physician's orders - regardless of what those orders were.. After the intubation, I found out that many physicians give orders like this.....

I feel sick thinking about this, and I will definitely handle this differently in the future.... I think clarifying with the physician and making it about my own learning is a good approach.

TexanTough · Dec 14, 2014

" However, she gave me direct orders: "you must follow exactly what the physician tells you to do," plain and simple. "

RnExplorer: Your charge nurse has done a great disservice to you by saying this. (Warning: Soapbox). Yes you are a new nurse and may not have the clinical background/knowledge base to question a physician. However, if you have this visceral feeling something doesn't 'seem' right, by all means question it. I don't care if it's the chief of cardio-thoracic surgery barking orders.

In no way should you ever blindly follow a physicians orders. Your role is to question and critically think about the global implications of what is about to happen.

You should not be giving a paralytic first. The only exception would be an already obtunded patient who risks losing their airway in the immediate. Even then, most providers will administer a sedative first to unresponsive patients so long as their is little risk for further hemodynamic insult. I see suggestions of being a cutesy nursing and 'suggesting' a dost of etomidate. I cut out the cutesy and simply say, " Let's give a sedative first please and then we will talk our paralytic dosing."

Beware the charge nurse that tells you to do whatever a physician says.

RNexplorer · Dec 14, 2014

" However, she gave me direct orders: "you must follow exactly what the physician tells you to do," plain and simple. "
RnExplorer: Your charge nurse has done a great disservice to you by saying this. (Warning: Soapbox). Yes you are a new nurse and may not have the clinical background/knowledge base to question a physician. However, if you have this visceral feeling something doesn't 'seem' right, by all means question it. I don't care if it's the chief of cardio-thoracic surgery barking orders.
In no way should you ever blindly follow a physicians orders. Your role is to question and critically think about the global implications of what is about to happen.
You should not be giving a paralytic first. The only exception would be an already obtunded patient who risks losing their airway in the immediate. Even then, most providers will administer a sedative first to unresponsive patients so long as their is little risk for further hemodynamic insult. I see suggestions of being a cutesy nursing and 'suggesting' a dost of etomidate. I cut out the cutesy and simply say, " Let's give a sedative first please and then we will talk our paralytic dosing."
Beware the charge nurse that tells you to do whatever a physician says.

I agree with you about all of this... I feel awful that I did what I did. I guess I need to have more confidence in my own knowledge and intuition. I don't know why I followed the charge nurse's instruction... maybe because she's the one with over 20 years experience and I was trying to learn from her all day? Maybe because I was scared of what could happen if I didn't follow the advice? I knew that sedation first was important, but in the moment I doubted myself.

Anyhow, I've learned a lot from this situation... I've always got to think for myself, regardless of what anyone else says.

Loo17 · Dec 14, 2014

I agree with you about all of this... I feel awful that I did what I did. I guess I need to have more confidence in my own knowledge and intuition. I don't know why I followed the charge nurse's instruction... maybe because she's the one with over 20 years experience and I was trying to learn from her all day? Maybe because I was scared of what could happen if I didn't follow the advice? I knew that sedation first was important, but in the moment I doubted myself.
Anyhow, I've learned a lot from this situation... I've always got to think for myself, regardless of what anyone else says.

Also know your doses for the common meds the docs use. There have been several instances the residents have told me to push a dangerously wrong dose and I have had to ask them what they were calculating the patients weight at because the dose was too high. Usually they were using the wrong mg/kg.