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: 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????"
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??" 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........
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: Is this seriously happening I'm thinking??? This is someones grandfather, someones father, Would you want this done to your family member????
"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...."
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....
I think the message in that post was it is inhumane to give paralytics only without sedation which is sometimes done. Some don't give enough sedation or forget as long as the patient is not moving. There are a few situations where giving just the paralytic might be necessary but very, very few.
Agree with this. There's probably also a lot of situations where we should be waiting, topicalizing the patient and tubing them awake.
Agree with this. There's probably also a lot of situations where we should be waiting, topicalizing the patient and tubing them awake.
I wouldn't exactly want a patient fully awake either. Intubation is a scary, gaggy and even painful procedure. The patient is entitled to be as comfortable as possible. A little Hurricane spray isn't always going to be enough. Sometimes the BP creates a problem but usually that can be corrected. If someone knows how to use the BVM, you may have some time and don't have to rush and make a mess of the patient.
We also don't do nasal intubations unless it is in the OR for ENT type surgeries.
I read this thread, but I'm still puzzled how someone can be both alert AND lethargic.
Also, the OP's description of the patient's reaction to intubation is the exact ame reaction I get when I pass an NG down any patient that's not obtunded. (Minus the dramatic desat, of course.)
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
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: 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????"
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??" 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........
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: Is this seriously happening I'm thinking??? This is someones grandfather, someones father, Would you want this done to your family member????
"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...."
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....
To the original poster:
Based on what you have described/said - this MUST be reported. This is unprofessional, cavalier and non-patient centered care. typically this doesn't happen just once, rather it has probably happened before and will probably happen again.
Follow your facility's reporting process, discuss with your nurse manager first and see what to do, they can advise you if the next step is to move it to nursing admin formally or over to medical staff or just what. Explain to each nursing manager/leader you talk to that if there is any delay in processing this report/complaint that you are prepared to send a letter to the board of nursing asking them to support you in reporting to your state board of medicine.
It's not your call or my call if this is improper behavior or not, but at a minimum, it raises a "concern" that this may have been improper and at a minimum some peer-review by the medical staff is in order. If it makes you feel more comfortable, look up your state's whistle blower laws and protections. I do believe you are describing unsafe patient care and I believe as a licensed nurse, you do have a responsibility to report and probably a liability if you don't report it.
Please let us know what you find out.
Remember, this behavior is likely to be repeated until it is stopped.
PS: you may even have an "anonymous" corporate compliance process (or something similar) to get advice from.
I wouldn't exactly want a patient fully awake either. Intubation is a scary, gaggy and even painful procedure. The patient is entitled to be as comfortable as possible. A little Hurricane spray isn't always going to be enough. Sometimes the BP creates a problem but usually that can be corrected. If someone knows how to use the BVM, you may have some time and don't have to rush and make a mess of the patient.
We also don't do nasal intubations unless it is in the OR for ENT type surgeries.
If your docs are topicalizing with just Hurricane spray they're not doing enough. I'm talking nebulizer lidocaine, lidocaine applied directly to the cords via atomization, and pain control waiting immediately at bedside. Sedation isn't necessarily the most important component anyway, but intubation is a painful procedure.
Nasal intubations create a host of issues in the long term mechanical ventilation patient.
Like I said unless there is a very good reason.....sedation, and paralytics.....
The "very good reasons" are fairly common in the population of patients that gets tubed. Morbid obesity, limited neck mobility, obstructive sleep apnea, small thyromental space, limited mouth opening...the list goes on and on.
I'm curious why your so keen on the use of a paralytic. There's only one reason we routinely use a paralytic for RSI, I'm curious how many people are aware of what it is.
The "very good reasons" are fairly common in the population of patients that gets tubed. Morbid obesity, limited neck mobility, obstructive sleep apnea, small thyromental space, limited mouth opening...the list goes on and on.
I'm curious why your so keen on the use of a paralytic. There's only one reason we routinely use a paralytic for RSI, I'm curious how many people are aware of what it is.
Paralytics are used in RSIs to 1. prevent Mendleson's Syndrome/Aspiration Pneumonitis, 2. To prevent laryngospasm, 3. To improve view 4. To make ventilation easier.
Using a paralytic ,specifically the one depolarizing paralytic, is still considered the gold standard in RSIs. Most people IMO that don't intubate all the time will struggle if there isn't a paralytic on board.
Paralytics are used in RSIs to 1. prevent Mendleson's Syndrome/Aspiration Pneumonitis,
The one I was specifically looking for. Preventing active regurg in the non-NPO patient.
2. To prevent laryngospasm
Yes, but I've tube plenty of non-paralyzed patients who never experienced laryngospasm, and it can be administered after the spasm occurs if need be.
3. To improve view
Maybe, maybe not. I've seen it worsen views as well.
4. To make ventilation easier.
It does, assuming the operator is competent.
Using a paralytic ,specifically the one depolarizing paralytic, is still considered the gold standard in RSIs.
It's not really an RSI without a paralytic. But I don't buy the "thiopental/sux" hype. That was the best options available back when RSI was developed by anesthesia. Since then we've found better induction agents, and it's arguable how much clinical difference sux'a rapid onset truly makes for it's long list of side effects (that said, I still like sux). The argument I'm making however, is that RSI'ing a poor candidate is far more negligent than choosing a different option such as awake intubation, Ketamine sedation, ect.
Most people IMO that don't intubate all the time will struggle if there isn't a paralytic on board.
Honestly people who don't do a lot of intubations probably don't need to be doing elective/semi-elective intubations in poor candidates for RSI. Which may be the best take away message. Unless your educated, trained and have some experince in advanced airway management, don't pressure the provider holding the laryngoscope into using your preferred method because it's "humane". They may have a reason for taking the approach they are.
FYI: thiopental is no longer manufactured, and most anesthesia providers weren't using it for RSIs before it was discontinued.
A patient that is actively fighting against the intubation is much more likely to have poor outcomes than one that is sedated/induced properly. There was nothing in the OPs description that would have lead someone to believe that the patient needed an awake intubation.
: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????" 
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........ 
usalsfyre
194 Posts
Agree with this. There's probably also a lot of situations where we should be waiting, topicalizing the patient and tubing them awake.