Is this fallout from JCAHO? Recent ER visit...

[Malanya]

Hi, it's been awhile. Hope you guys are keeping on keeping on. I've been doing fairly well, but my asthma has been requiring more vigilance to keep it fully under control lately, and it doesn't seem to take much to get me sick. I had to go to the ED for an exac recently, though, and while most of the visit was routine, the way pain was addressed on a completely non-pain related visit kinda shocked me. Is this just the way things are now?

The full story:

The weekend right before Halloween I managed to sprain my back trying to work on my new house. When I went in to see my PCP he noted that I was wheezing a bit more than normal, we made a note that next visit I needed to get my PFTs redone, and I learned the power of Toradol for the first time (the shot took a bit to start working but within half an hour I could have kissed that doctor). When I'd had orthopedic pain before he'd written Celebrex and it worked well, so he wrote that as well as some Flexeril... and Vicodin, which may have been the mistake.

Over that next week my back slowly got better, but my breathing got much worse -- I had to use my rescue inhaler twice the first night on it. I had also been fighting nausea all week -- coughing too much does it to me, plus I'm sure the narcs added their contribution. I only needed the Vicodin at night by the end of the week, so that's the only time I was taking it, but by Sunday night I had the full-on crud and was running a fever hacking puking all night.... and my doctor was already booked up for the entire day on Monday when I got through. I made an appointment for the next day but I guess I sounded bad because I got a callback 15 minutes later from my doctor, who asked me a few questions, had me use my rescue inhaler six times in a row... then told me to go to the ER because I still wasn't able to speak in complete sentences. Fortunately a friend was able to drive me, I really didn't trust myself behind the wheel, and I was right -- O2 sat 87 in triage.

The triage nurse learned about the back problem because of my current medications, but when she asked my pain levels I said "Maybe a 2 but it's not on my radar at all right now." It wasn't. Everything seemed pretty standard after that -- saline lock, blood, UA, they did a chest x-ray and then a resp tx... I was still pretty wheezy after but I did respond some.

Then this is when it started to get weird, or at least it felt odd to me.

The doctor apparently ordered fluids and Zofran, and another resp tx for after the fluids were started, but also Ativan. And I got the feeling the nurse was uncomfortable with the dose ordered of Ativan, or at the very least she was trying to do her best not to snow me completely with it (I don't know what amount was ordered but I'm only 5'1 and 130 lbs, doesn't take much for me)... she pushed the Zofran but she spaced the Ativan out in the line so it wouldn't knock me straight out. As it was, I could barely finish the second resp tx. I won't deny I needed the rest, and I was happy to sleep without struggling to breathe or struggling not to puke, but I'd never been sedated in the ER before.

After a few hours the doctor woke me up and listened to my breathing, said that the chest xray and labs were all good (yay!) but he wanted me to follow up with my doctor... He wrote Phenergan and Cipro, then said that he thought I should have an antibiotic and steroid shot as well, and that the nurse would be in. I was still pretty dazed. When the nurse came in, she said, "By the way, the doctor was worried about you, he said you were crying out in your sleep." I said I didn't know why, that "my back hurts a little, but..." and started to say I had meds at home for that. She cut me off. "Well, this morphine will fix that."

?????????

I was *extremely* surprised, and the only thing I could think of to say in response to that was "Well, if you're going to do that I'm doubly glad that my friend was able to drive me today." I accepted the medication... I figured it meant I wouldn't have to take any of my home medication the rest of the night, and knew I wouldn't be behind the wheel. After that and the Rocephin/Decadron my friend came and picked me up, took me home and put me to bed, then went and got my scripts filled for me -- I was barely able to keep my eyes open on the way home.

--------

When I followed up with my PCP I asked about getting a home nebulizer so that I can give myself breathing treatments if I need to instead of having to go to the ER, and he seems to think it's a good idea, so hopefully I won't have to go back to the ER for a long time.

But is it standard to administer narcs in a situation like that? Honestly, I would have been happier with Toradol now that I've had it once and know how well it works -- I don't like the nausea and sleepiness from narcs. It just seems backwards to have gotten an anti-inflammatory shot when I was in absolute agony and narcs when I wasn't even c/o of pain as my reason for being there.

[vanburbian]

ativan & morphine are not too terribly uncommon in pt.'s presenting with resp distress.

Depends on the doc. of course, but morphine is a good drug for some people with resp exacerbation/SOB, IMO.

Toradol is a fantastic drug for muscle/bone & joint pain. But, I don't know that a doc would have used it in the circumstances you describe for this ER visit.

[GM2RN]

ativan & morphine are not too terribly uncommon in pt.'s presenting with resp distress.

Depends on the doc. of course, but morphine is a good drug for some people with resp exacerbation/SOB, IMO.

Toradol is a fantastic drug for muscle/bone & joint pain. But, I don't know that a doc would have used it in the circumstances you describe for this ER visit.

I agree with this. Our docs will order small doses of morphine sometimes, even with no or little complaint of pain for those who have come in with difficulty breathing.

[Esme12, ASN, BSN, RN]

I agree with this. Our docs will order small doses of morphine sometimes, even with no or little complaint of pain for those who have come in with difficulty breathing.

I find the story odd. Although I have seen Ativan or MOrphine for patients with SOB....I find it odd that they would give morphine upon discharge. Did the MD do this in response to a JACHO visit? Were they there and how did you know they had a visit? (just curious) But I don't think it had anything to do with JACHO.

Glad you are feeling better.:)

[Trekfan]

I think it was the er you went to . I unfortunately have been to er maney times and rearly was pain meds offered to me . The I had an inpaction I and the nurse I had to fight for a little pain meds .

When I was admitted to the hospital and waiting for bed in the er I was in so much pain i was on my hands and knees rocking for for wait seemed like hours.

[MassED, BSN, RN]

and all that I could think about in reading your post, OP, was that Toradol can cause Asthma exacerbation......

but other than that, doctors sometimes prescribe meds that they feel are appropriate, even though you might not believe so. You might have been dreaming, but he/she believed you were in pain. I, as the nurse, would have evaluated that and decided to give or not to give you pain med depending on my assessment.

Hope you're better.

[maelstrom143]

In our old ER we used Ativan to decrease anxiety caused by respiratory distress and morphine to decrease dypsnea and resp rate. Morphine causes respiratory depression, which in turn can alleviate SOB/dyspnea, thereby making it easier to breathe. Respiratory rate being depressed might be a bad thing, except when you are talking about a person in acute respiratory distress who is breathing too fast and therefore probably not efficiently.

Oh, also had one patient who received nebulized morphine in a GA hospital (end stage COPD).

[Spidey's mom, ADN, BSN, RN]

We use morphine in the ER for SOB because it relaxes the muscles in the bronchial tubes, making it easier to breath. It can also help control the anxiety associated with feeling suffocated while attempting to breath. We use Ativan for that also.

We've used (IV) morphine in the nebulizer too - although some research suggests this isn't all that helpful and it is better to give IV or PO (liquid).

I think what you got would have been pretty standard where I work.

And I agree with MassED . . . as good as Toradol is for ortho pain, it can exacerbate asthma symptoms.

[Medic/Nurse, BSN, RN]

My opinion is that JCAHO has ZERO to do with any of the events that you describe from your recents visits.

Personally, I have never seen a joint commission visit influence the meds a patient receives. Now - had you told me there were exceptional amounts of paper given to you from your visit including extensive education and patient rights - I'd think that there might be a JCAHO directive.

Feel Better!

:angel:

[Altra, BSN, RN]

What did your CXR look like? I don't commonly see abx prescribed for asthma exacerbations. COPD - yes. Asthma - no.

Your back pain may have set you up for the classic shallow breathing/restricted chest movement pneumonia deal. Relieve the pain, and breathing becomes more comfortable.

[Emergency RN]

No offense to the OP, but you're talking aspects of your own medical care and treatment (and not a neutral clinical question), which is actually not appropriate for this forum per the Terms of Service. I suggest a moderate please review this thread.

[Trekfan]

No offense to the OP, but you're talking aspects of your own medical care and treatment (and not a neutral clinical question), which is actually not appropriate for this forum per the Terms of Service. I suggest a moderate please review this thread.

There are LOTS of other post where people and talking about being in the er or hospital . Hers Is no different them the others .