Intubation without RSI meds??

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Specializes in ER, Cardiac Tele/ICU Stepdown.

I haven't been on here in forever, but I had to vent about this!!!

Today I was involved with a rapid sequence intubation of a COPD'er whose CO2 was 136 (I know, impressive right??) The doctor rushes into the room, the patient is lethargic but alert and his eyes are wide open. The MD immediately runs to the head of the bed laryngoscope and tube in hand..... I am taking over this patient from another nurse, and I immediately ask if the patient has received any sedatives at all? His response is "No" :uhoh3: :uhoh3: Another nurse runs to the pyxis and grabs out a RSI kit (has succs, etomidate, etc in it) The nurse runs back into the room and is holding up the bag of meds "Are you going to order RSI meds????" :confused:

We stand back in sheer shock and disbelief as the doctor rams the laryngoscope down the patients throat as he is wide awake now and GAGGING!!!! He does not answer the nurse and continues to try to tube the patient, the patient is choking, gagging and fighting the tube as best he can. He desats to the 70s and finally the doctor stops. :smackingf

We ask AGAIN "Doc, what do you want to give this patient to sedate him??" :mad: As we're bagging the patient back up to the 90s, he states "I want to try it again" And starts attempting intubation AGAIN, with the patient choking and gagging.... One nurse walking out of the room, mumbling something like "this is BS" Finally, the doctor gets the tube in place, hands it to RT to get on the vent, I start bagging and the MD immediately starts heading for the door........ :eek:

At this point I'm LIVID, I'm bagging the patient and I cannot even ventilate him because he is choking on the tube and the patient starts grabbing at it "Doc, we gotta knock this guy down, quick, this isn't right" The MD states "We got the airway, that's what's important" :confused::confused::confused: Is this seriously happening I'm thinking??? This is someones grandfather, someones father, Would you want this done to your family member???? :crying2:

"DOC, it doesn't matter if he has an airway, I CANNOT ventilate him, he's choking! And he's gonna pull this thing out!" He finally mumbles "Fine, I'll order some propofol...." :idea:

He orders a measly 30mg bolus for a patient of 113kg and tells me to start slow with the drip because he's worried about his pressure (which is 160s systolic at this point)....... Get my bolus given, throw the gtt up at 20 mcg's, and titrate it all the way up to 50mcg's, (while monitoring his pressure of course) until FINALLY this poor man is sedated....

This seriously ripped my heart out of my chest....... Would I want my mother treated in this manner???? As I'm titrating the gtt and the poor guy is still choking on the tube, I tell him "I'm going to get you comfortable as quickly as I can"

Is there any excuse for this??? Is there any reason at all that there could be no meds given prior to the intubation? Nothing?? This seriously ruined my day....

Thanks for letting me vent.... :nurse:

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Specializes in Critical Care, Progressive Care.

Good heavens- what a horrid scene. Sorry your pt went through this. Did the pt consent or assent to intubation? WWhat is wrong with the MD? Is this standard for this guy? If so, I would work on getting him out.

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Specializes in ER, Cardiac Tele/ICU Stepdown.

Yes, it was horrid!!! I felt so sorry for this poor man. The family consented to the intubation. I've never been in with this particular MD for an intubation, he seemed frazzled, even said to the family (who happened to somehow be let in during the procedure) "He's not going to make it............" After a long pause "without intubation"........... This was so wrong in so many ways.....

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Specializes in CEN, CPEN, RN-BC.

Wow... just wow. I feel so bad for this guy. I hate when people believe that one drug that knocks someone out encompasses every aspect of analgesia, anxiolysis, amnesia, etc... When we intubate someone with RSI, I always advocate for some versed and fentanyl if their pressure can take it. I shudder at the thought of being paralyzed and fully aware of what's going on, without being able to do anything about it.

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Specializes in ER/Trauma.

Totally not cool.

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Specializes in ICU/CCU.

Horrible.

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This happened to me several years ago. :crying2:

I was a frequent flier in the ED (the 'mean one'), and to this day don't know why I was there or who called 911 for that particular visit. I was just waking up and recognized the ceiling tiles, so knew where I was. No call light. I could see a doc coming in the room. He went to the head of the bed- didn't notice I was awake (or care), didn't talk to me, NOTHING. He then inserted the laryngoscope, at which time I promptly puked. He also was alone- no nurse or RT to suction.

So, I'm trying to turn my head to not choke- he's got the scope still down, and a couple of nurses came in. He demands I be restrained. In the meantime, I turned my head to the right, to get rid of the puke, and the scope cuts my tonsil. So now I'm spitting out blood clots. And restrained. He leaves, and the nurses got me straightened out... I was apologizing for throwing up, and felt horrible that they had that to deal with.

Dr. Dipsh*t shows back up, and speaks to me for the first time during this whole thing- he asked if I OD'd.... I told him no- which was true- I had no idea why I was there, but ODing wasn't my thing (dysautonomia, epilepsy, and a lousy bunch of drug interactions would bottom my BP out BAD- like 4 liters of fluids to get a SBP into the low 80s, and ICU monitoring for possible dopamine type interactions...). He then says "well, that's all YOU had to say"..... I was thinking "that's all YOU had to ask".

It was terrifying. I had no chance to tell this guy anything- and was obviously having some problem to not remember getting there, so a bit delayed in response time.

I've got a list of things that went on in that place- that is now merging with a decent place. God help them all....

BTW, I figured out myself what the drug interactions were, and haven't had hypotensive TIAs, or the weird hypotensive episodes (other than the dysautonomia) since then... and I use a different hospital now...:)

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This is crazy.....back in the late 90's I remember a phase anesthesia went through where they were doing "trans tracheal blocks?" Does anyone else remember these?

The patients were fully awake a small gauge needle was essentially stuck in their neck "to freeze them" then the patients were tubed.....most of them kicking and screaming. It was one of the worst things I have ever witnessed.

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Specializes in Emergency Dept, ICU.

Yeah I can see the sadness here, some sedation would have been nice. But even awake you should have been able to ventilate him if the ET was correctly placed. You generally don't choke on a tube when it's in your trachea.

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Specializes in Telemetry, ICU/CCU, Specials, CM/DM.

I cannot believe a doctor would treat a patient like that. I feel sorry for his patients. I, personally, would have written that doctor up and sent it to administration (which I've done before for other reasons and a couple doctors were not allowed to practice at our hospital anymore). This should not be tolerated!!!!

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Hope that patient or family files a complaint. That's poor practice and makes me sick.

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Specializes in ER/ICU/STICU.

Unacceptable. He is lucky the patient didn't vomit and aspirate. I would kick this up to the nurse manager and let them deal with it. Maybe even get risk management involved. A "frazzled" ER doctor that is stubborn and doesn't listen is a very dangerous combination.

An incident report isn't a bad idea either.

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